Provider Demographics
NPI:1376837807
Name:TATE, JOHN TYLER (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TYLER
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 1:3101 E STATE HIGHWAY 114 STE A
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6639
Mailing Address - Country:US
Mailing Address - Phone:817-481-6364
Mailing Address - Fax:817-329-2296
Practice Address - Street 1:3101 E STATE HIGHWAY 114 STE A
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6639
Practice Address - Country:US
Practice Address - Phone:817-481-6364
Practice Address - Fax:817-329-2296
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX265651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice