Healthcare Provider Details

I. General information

NPI: 1326204009
Provider Name (Legal Business Name): MARTY R LIPSEY DDS MS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 06/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 STANDIFORD AVE SUITE H
MODESTO CA
95350-1000
US

IV. Provider business mailing address

26626 BROOKS CIR
STEVENSON RANCH CA
91381-1459
US

V. Phone/Fax

Practice location:
  • Phone: 209-527-1995
  • Fax: 877-641-2283
Mailing address:
  • Phone: 209-527-1995
  • Fax: 866-527-2335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number26675
License Number StateCA

VIII. Authorized Official

Name: DR. MARTY R LIPSEY
Title or Position: PRESIDENT
Credential: DDS MS
Phone: 209-527-1995