Provider Demographics
NPI:1528281904
Name:LIVESAY, THOMAS GRANVILLE (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:GRANVILLE
Last Name:LIVESAY
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 1:5576 JACLYN DRIVE
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20187
Mailing Address - Country:US
Mailing Address - Phone:540-349-5759
Mailing Address - Fax:
Practice Address - Street 1:1805 PLAZA DRIVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601
Practice Address - Country:US
Practice Address - Phone:540-535-0401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401006601122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist