Provider Demographics
NPI:1881782365
Name:LIVENGOOD, GAIL G (DDS)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:G
Last Name:LIVENGOOD
Suffix:
Gender:F
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 568
Mailing Address - Street 2:
Mailing Address - City:LOCKHART
Mailing Address - State:TX
Mailing Address - Zip Code:78644-0568
Mailing Address - Country:US
Mailing Address - Phone:512-398-3429
Mailing Address - Fax:512-398-2233
Practice Address - Street 1:701 STATE PARK ROAD
Practice Address - Street 2:
Practice Address - City:LOCKHART
Practice Address - State:TX
Practice Address - Zip Code:78644
Practice Address - Country:US
Practice Address - Phone:512-398-3429
Practice Address - Fax:512-398-2233
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX125661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0909533Medicaid