Healthcare Provider Details

I. General information

NPI: 1083789903
Provider Name (Legal Business Name): MITCHELL JAY LIPP DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 OCEAN PARKWAY SUITE 1M
BKLYN NY
11235
US

IV. Provider business mailing address

2650 OCEAN PARKWAY SUITE 1M
BKLYN NY
11235
US

V. Phone/Fax

Practice location:
  • Phone: 718-769-9293
  • Fax: 718-891-3718
Mailing address:
  • Phone: 718-769-9293
  • Fax: 718-891-3718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0395021
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: