Provider Demographics
NPI:1275670218
Name:LIPTAK, ROBERT J (DMD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:LIPTAK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-3638
Mailing Address - Country:US
Mailing Address - Phone:413-533-8378
Mailing Address - Fax:413-534-3989
Practice Address - Street 1:610 SOUTH ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-3638
Practice Address - Country:US
Practice Address - Phone:413-533-8378
Practice Address - Fax:413-534-3989
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0222488Medicaid