Provider Demographics
NPI:1528166097
Name:TATE, SCOTT ERIC (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ERIC
Last Name:TATE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 N MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1067
Mailing Address - Country:US
Mailing Address - Phone:812-323-9700
Mailing Address - Fax:812-323-9701
Practice Address - Street 1:707 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1067
Practice Address - Country:US
Practice Address - Phone:574-289-0080
Practice Address - Fax:812-323-9701
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ12010196A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200494170Medicaid
INV01269Medicare UPIN