Provider Demographics
NPI:1568023471
Name:ANDERSON, TATE EZRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:TATE
Middle Name:EZRA
Last Name:ANDERSON
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 1:337 GREYBULL AVE
Mailing Address - Street 2:
Mailing Address - City:GREYBULL
Mailing Address - State:WY
Mailing Address - Zip Code:82426-2049
Mailing Address - Country:US
Mailing Address - Phone:307-765-4654
Mailing Address - Fax:
Practice Address - Street 1:337 GREYBULL AVE
Practice Address - Street 2:
Practice Address - City:GREYBULL
Practice Address - State:WY
Practice Address - Zip Code:82426-2049
Practice Address - Country:US
Practice Address - Phone:307-765-4654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-23
Last Update Date:2019-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY15351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice