Provider Demographics
NPI:1083789903
Name:LIPP, MITCHELL JAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:JAY
Last Name:LIPP
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 OCEAN PARKWAY
Mailing Address - Street 2:SUITE 1M
Mailing Address - City:BKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235
Mailing Address - Country:US
Mailing Address - Phone:718-769-9293
Mailing Address - Fax:718-891-3718
Practice Address - Street 1:2650 OCEAN PARKWAY
Practice Address - Street 2:SUITE 1M
Practice Address - City:BKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235
Practice Address - Country:US
Practice Address - Phone:718-769-9293
Practice Address - Fax:718-891-3718
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY03950211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01059970Medicaid