Provider Demographics
NPI:1487386801
Name:LIVELY, MADISON COMER (DMD)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:COMER
Last Name:LIVELY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 AMESBURY DR APT 365
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-4838
Mailing Address - Country:US
Mailing Address - Phone:678-520-3422
Mailing Address - Fax:
Practice Address - Street 1:106 N COTTONWOOD DR
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-4736
Practice Address - Country:US
Practice Address - Phone:972-231-5376
Practice Address - Fax:972-231-6074
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-24
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN122708122300000X
TX38808122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist