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General NPI Number Information
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NPI Number | 1003811100
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Entity Type | Organization
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Legal Business Name | TATE FAMILY DENTISTRY, PA
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Dates
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Enumeration Date | 06/15/2005
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Last Update Date | 12/15/2014
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Provider Practice Location Address
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Address Line | 3101 E STATE HIGHWAY 114 STE A
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6690
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Country | US
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Telephone | 817-481-6364
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Fax | 817-329-2296
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Provider Business Mailing Address
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Address Line | 3101 E STATE HIGHWAY 114 STE A
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6690
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Country | US
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Telephone | 817-481-6364
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Fax | 817-329-2296
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Authorized Official
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Title or Position | SECRETARY
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Name | DR. JOHN TYLER TATE
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Credential | D.D.S.
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Telephone | 817-481-6364
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | TX11540
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License Number State | TX
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