=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528166097
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT ERIC TATE DDS, MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 04/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 707 N MICHIGAN ST
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46601-1067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-289-0080
-----------------------------------------------------
Fax | 812-323-9701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 707 N MICHIGAN ST
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46601-1067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-323-9700
-----------------------------------------------------
Fax | 812-323-9701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | IN12010196A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------