Provider Demographics
NPI:1811682420
Name:LIVESAY, GREGORY PAUL
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:PAUL
Last Name:LIVESAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 RANDY LN
Mailing Address - Street 2:
Mailing Address - City:FARMERS BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:75234-6428
Mailing Address - Country:US
Mailing Address - Phone:210-777-3500
Mailing Address - Fax:
Practice Address - Street 1:3300 GASTON AVENUE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246
Practice Address - Country:US
Practice Address - Phone:214-828-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty