MEDICARE: ELZIE LEE TATE III D.M.D.

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	1223G0001X	General Practice Dentistry	1903	SC

General Provider Information

NPI Number	:	1881732691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELZIE LEE TATE III D.M.D.

Provider Business Mailing Address
First Line	:	19309 ASHEVILLE HWY
Second Line	:
City	:	LANDRUM
State	:	SC
Zip	:	29356-9130
Country	:	US
Telephone Number	:	864-457-4037
Fax Number	:	864-599-7804

Provider Business Practice Location Address
First Line	:	8737 ASHEVILLE HWY
Second Line	:
City	:	SPARTANBURG
State	:	SC
Zip	:	29316-4609
Country	:	US
Telephone Number	:	864-578-5812
Fax Number	:	864-599-7804

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

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	07/08/2007

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