Provider Demographics
NPI:1194980227
Name:JAMES G. LIVINGSTON, DDS.,PC
Entity type:Organization
Organization Name:JAMES G. LIVINGSTON, DDS.,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GARRY
Authorized Official - Last Name:LIVINGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-883-4337
Mailing Address - Street 1:PO BOX 1709
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:WY
Mailing Address - Zip Code:83110-1709
Mailing Address - Country:US
Mailing Address - Phone:307-883-4337
Mailing Address - Fax:307-885-4334
Practice Address - Street 1:800 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110-1709
Practice Address - Country:US
Practice Address - Phone:307-885-4337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805327400Medicaid
WY112487100Medicaid