Healthcare Provider Details

I. General information

NPI: 1114290988
Provider Name (Legal Business Name): ST. CHARLES FAMILY DENTRISTRY L.T.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 02/09/2012
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:
Mailing address:
  • Phone: 630-377-3131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. EDMUND A LIPSKIS
Title or Position: OWNER
Credential: D.D.S.
Phone: 630-377-3131