MEDICARE: JACK I. LIPTON D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	60861	CA
2	1223G0001X	General Practice Dentistry	D4375	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	60861	OTHER	CA	DENTAL LICENSE

General Provider Information

NPI Number	:	1841228137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK I. LIPTON D.M.D.

Provider Business Mailing Address
First Line	:	1754 S FORT APACHE RD # 1
Second Line	:
City	:	CAMP VERDE
State	:	AZ
Zip	:	86322-6909
Country	:	US
Telephone Number	:	480-329-6684
Fax Number	:

Provider Business Practice Location Address
First Line	:	1754 S FORT APACHE RD # 1
Second Line	:
City	:	CAMP VERDE
State	:	AZ
Zip	:	86322-6909
Country	:	US
Telephone Number	:	480-329-6684
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	09/21/2018

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