Provider Demographics
NPI:1073875852
Name:MARTY R. LIPSEY, DDS, MS, INC
Entity Type:Organization
Organization Name:MARTY R. LIPSEY, DDS, MS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:LIPSEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:209-380-5486
Mailing Address - Street 1:3025 MCHENRY AVE
Mailing Address - Street 2:SUITE N
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1466
Mailing Address - Country:US
Mailing Address - Phone:209-527-1995
Mailing Address - Fax:866-527-2335
Practice Address - Street 1:2421 HARTNELL AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-2340
Practice Address - Country:US
Practice Address - Phone:209-527-1995
Practice Address - Fax:866-527-2335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-08
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26675261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental