Provider Demographics
NPI:1386748663
Name:BUSSE, WALTER BERGE (DDS)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:BERGE
Last Name:BUSSE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 E 162ND STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473
Mailing Address - Country:US
Mailing Address - Phone:708-331-2322
Mailing Address - Fax:708-596-3128
Practice Address - Street 1:536 E 162ND STREET
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473
Practice Address - Country:US
Practice Address - Phone:708-331-2322
Practice Address - Fax:708-596-3128
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
603950Medicare UPIN
ILL19900Medicare ID - Type Unspecified