=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235417163
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY JAMES LIVINGSTON DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2011
-----------------------------------------------------
Last Update Date | 12/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 S WASHINGTON ST
-----------------------------------------------------
City | AFTON
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 83110-9410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-885-4337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 S WASHINGTON ST
-----------------------------------------------------
City | AFTON
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 83110-9410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-885-4337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 6979
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 1292
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 9197972-9921
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------