Healthcare Provider Details

I. General information

NPI: 1154531754
Provider Name (Legal Business Name): HAROLD MARK LIVINGSTON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST UNIVERSITY OF MISSISSIPPI SCHOOL OF DENTISTRY
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST UNIVERSITY OF MISSISSIPPI SCHOOL OF DENTISTRY
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-6028
  • Fax: 601-984-6039
Mailing address:
  • Phone: 601-984-6028
  • Fax: 601-984-6039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2622-91
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: