MEDICARE: DR. TATE MICHAEL DISON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D14227	MN

General Provider Information

NPI Number	:	1295394989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TATE MICHAEL DISON DDS

Provider Business Mailing Address
First Line	:	5039 HIGHWAY 52 N
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55901-0166
Country	:	US
Telephone Number	:	507-282-7905
Fax Number	:

Provider Business Practice Location Address
First Line	:	5039 HIGHWAY 52 N
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55901-0166
Country	:	US
Telephone Number	:	507-282-7905
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2019
Last Update Date	:	06/06/2019

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