Provider Demographics
NPI:1487623104
Name:DENTATE PLLC
Entity type:Organization
Organization Name:DENTATE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:936-569-1111
Mailing Address - Street 1:508 RUSSELL BLVD
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1244
Mailing Address - Country:US
Mailing Address - Phone:936-569-1111
Mailing Address - Fax:936-564-0808
Practice Address - Street 1:508 RUSSELL BLVD
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1244
Practice Address - Country:US
Practice Address - Phone:936-569-1111
Practice Address - Fax:936-564-0808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00603EMedicare PIN