Provider Demographics
NPI:1295839769
Name:TATE, FREDERICK BRYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:BRYAN
Last Name:TATE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 EASTWOOD RD
Mailing Address - Street 2:STE 105
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403
Mailing Address - Country:US
Mailing Address - Phone:910-256-9040
Mailing Address - Fax:910-256-2463
Practice Address - Street 1:2002 EASTWOOD RD
Practice Address - Street 2:STE 105
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403
Practice Address - Country:US
Practice Address - Phone:910-256-9040
Practice Address - Fax:910-256-2463
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC67281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
646240OtherUNITED CONCORDIA
NC9016HOtherBCBS
NC97551Medicaid