=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235270554
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEROLD HAYES LIPSON DDS MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 680 UNIVERSITY AV
-----------------------------------------------------
City | PALO ALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-328-6120
-----------------------------------------------------
Fax | 650-328-1545
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 680 UNIVERSITY AV
-----------------------------------------------------
City | PALO ALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-328-6120
-----------------------------------------------------
Fax | 650-328-1545
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 19924
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------