=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902943525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIAMS & TATE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1254 E. EARL RD
-----------------------------------------------------
City | EAST EARL
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-354-7904
-----------------------------------------------------
Fax | 717-354-0754
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1254 E. EARL RD
-----------------------------------------------------
City | EAST EARL
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-354-7904
-----------------------------------------------------
Fax | 717-354-0754
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR. OFFICE COORDINATOR
-----------------------------------------------------
Name | MAE HIGH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 717-354-7904
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS030800R
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------