Healthcare Provider Details

I. General information

NPI: 1891859724
Provider Name (Legal Business Name): HALEY P TATE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W MAIN ST
NEW MARKET MD
21774-6204
US

IV. Provider business mailing address

108 W MAIN ST
NEW MARKET MD
21774-6204
US

V. Phone/Fax

Practice location:
  • Phone: 301-865-4434
  • Fax:
Mailing address:
  • Phone: 301-865-4434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11353
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: