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General NPI Number Information
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NPI Number | 1568023471
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Entity Type | Individual
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Provider Name | TATE EZRA ANDERSON DDS
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Gender | Male
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Dates
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Enumeration Date | 06/23/2019
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Last Update Date | 06/23/2019
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Provider Practice Location Address
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Address Line | 337 GREYBULL AVE
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City | GREYBULL
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State | WY
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Zip | 82426-2049
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Country | US
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Telephone | 307-765-4654
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Fax |
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Provider Business Mailing Address
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Address Line | 337 GREYBULL AVE
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City | GREYBULL
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State | WY
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Zip | 82426-2049
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Country | US
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Telephone | 307-765-4654
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 1535
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License Number State | WY
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