Provider Demographics
NPI:1356908719
Name:TATE, KAMBERLY D (DDS)
Entity type:Individual
Prefix:
First Name:KAMBERLY
Middle Name:D
Last Name:TATE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 HIGHWAY 85 N STE 310-154
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7738
Mailing Address - Country:US
Mailing Address - Phone:678-849-3493
Mailing Address - Fax:
Practice Address - Street 1:3006 N COUNTY ROAD 25A STE 202
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1372
Practice Address - Country:US
Practice Address - Phone:937-552-9028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.026693122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist