Provider Demographics
NPI:1649478587
Name:TATE, GEORGE WALLACE (DDS)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WALLACE
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:RR 1 BOX 664
Mailing Address - Street 2:ROCKY BOY HEALTH BOARD
Mailing Address - City:BOX ELDER
Mailing Address - State:MT
Mailing Address - Zip Code:59521-9797
Mailing Address - Country:US
Mailing Address - Phone:406-395-4486
Mailing Address - Fax:406-395-5850
Practice Address - Street 1:ROCKY BOY HEALTH BOARD
Practice Address - Street 2:RR 1 BOX 664
Practice Address - City:BOX ELDER
Practice Address - State:MT
Practice Address - Zip Code:59521-9797
Practice Address - Country:US
Practice Address - Phone:406-395-4486
Practice Address - Fax:406-395-5850
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA23831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice