Provider Demographics
NPI:1194998252
Name:TKACH, ELLEN E (DDS)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:E
Last Name:TKACH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1846 BELVIDERE RD
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2289
Mailing Address - Country:US
Mailing Address - Phone:847-223-0100
Mailing Address - Fax:847-223-6528
Practice Address - Street 1:1846 BELVIDERE RD
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2289
Practice Address - Country:US
Practice Address - Phone:847-223-0100
Practice Address - Fax:847-223-6528
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003995Medicaid