Healthcare Provider Details

I. General information

NPI: 1528166097
Provider Name (Legal Business Name): SCOTT ERIC TATE DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N MICHIGAN ST
SOUTH BEND IN
46601-1067
US

IV. Provider business mailing address

707 N MICHIGAN ST
SOUTH BEND IN
46601-1067
US

V. Phone/Fax

Practice location:
  • Phone: 574-289-0080
  • Fax: 812-323-9701
Mailing address:
  • Phone: 812-323-9700
  • Fax: 812-323-9701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberIN12010196A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: