Provider Demographics
NPI:1073527933
Name:LIVELY, DUSTIN CURT (DDS)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:CURT
Last Name:LIVELY
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:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:MANGUM
Mailing Address - State:OK
Mailing Address - Zip Code:73554-0126
Mailing Address - Country:US
Mailing Address - Phone:580-782-2552
Mailing Address - Fax:580-782-9266
Practice Address - Street 1:230 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554-4202
Practice Address - Country:US
Practice Address - Phone:580-782-2552
Practice Address - Fax:580-782-9266
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK53271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice