Healthcare Provider Details

I. General information

NPI: 1447026604
Provider Name (Legal Business Name): GARY LIVINGSTON PUTT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 WASHINGTON ST
HUNTINGDON PA
16652-1505
US

IV. Provider business mailing address

537 5TH ST
TYRONE PA
16686-1221
US

V. Phone/Fax

Practice location:
  • Phone: 814-643-9414
  • Fax:
Mailing address:
  • Phone: 814-682-2119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS044363
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: