Provider Demographics
NPI:1952893646
Name:GIFFORD, KATHARINE TATE (DMD)
Entity type:Individual
Prefix:DR
First Name:KATHARINE
Middle Name:TATE
Last Name:GIFFORD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KATHARINE
Other - Middle Name:
Other - Last Name:TATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2545 E MALLORY ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-1517
Mailing Address - Country:US
Mailing Address - Phone:480-603-8043
Mailing Address - Fax:
Practice Address - Street 1:1959 S VAL VISTA DR STE 118
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7357
Practice Address - Country:US
Practice Address - Phone:480-750-0017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0100361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice