Provider Demographics
NPI:1932813219
Name:LIVE OAK PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:LIVE OAK PEDIATRIC DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERAME
Authorized Official - Middle Name:
Authorized Official - Last Name:HAFEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-845-8831
Mailing Address - Street 1:8056 SHIN OAK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-2957
Mailing Address - Country:US
Mailing Address - Phone:210-441-3360
Mailing Address - Fax:210-441-3387
Practice Address - Street 1:8056 SHIN OAK DR STE 200
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-2957
Practice Address - Country:US
Practice Address - Phone:210-441-3360
Practice Address - Fax:210-441-3387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-10
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE