Provider Demographics
NPI:1639626518
Name:LIVINGSTON DENTAL CARE
Entity Type:Organization
Organization Name:LIVINGSTON DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:FREDERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-222-6061
Mailing Address - Street 1:422 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-3456
Mailing Address - Country:US
Mailing Address - Phone:406-222-6061
Mailing Address - Fax:406-222-6062
Practice Address - Street 1:422 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-3456
Practice Address - Country:US
Practice Address - Phone:406-222-6061
Practice Address - Fax:406-222-6062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT21041223G0001X
MT23181223G0001X
MT12991223G0001X
MT18351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty