Provider Demographics
NPI:1750677902
Name:LIVINGSTON, BLAKE GABRIEL (DDS)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:GABRIEL
Last Name:LIVINGSTON
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 1:13724 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-3625
Mailing Address - Country:US
Mailing Address - Phone:313-883-3050
Mailing Address - Fax:
Practice Address - Street 1:13724 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3625
Practice Address - Country:US
Practice Address - Phone:313-883-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI20372122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1750677902Medicaid