Healthcare Provider Details

I. General information

NPI: 1619060217
Provider Name (Legal Business Name): BRAD A LIPKIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N MILLS AVE SUITE 210
ORLANDO GA
32803
US

IV. Provider business mailing address

610 N MILLS AVE SUITE 210
ORLANDO GA
32803
US

V. Phone/Fax

Practice location:
  • Phone: 407-423-7667
  • Fax: 407-425-8629
Mailing address:
  • Phone: 407-423-7667
  • Fax: 407-425-8629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN16984
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: