Healthcare Provider Details

I. General information

NPI: 1417031550
Provider Name (Legal Business Name): EDMUND A LIPSKIS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E MAIN ST
ST CHARLES IL
60174-2133
US

IV. Provider business mailing address

516 E MAIN ST
ST CHARLES IL
60174-2133
US

V. Phone/Fax

Practice location:
  • Phone: 630-377-3131
  • Fax: 630-377-7204
Mailing address:
  • Phone: 630-377-3131
  • Fax: 630-377-7204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: