Provider Demographics
NPI:1609103803
Name:KIPP, DERYL PALMER (DDS)
Entity Type:Individual
Prefix:DR
First Name:DERYL
Middle Name:PALMER
Last Name:KIPP
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 1:765 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:ME
Mailing Address - Zip Code:04530-2496
Mailing Address - Country:US
Mailing Address - Phone:207-443-3220
Mailing Address - Fax:207-443-5462
Practice Address - Street 1:765 HIGH ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:ME
Practice Address - Zip Code:04530-2496
Practice Address - Country:US
Practice Address - Phone:207-443-3220
Practice Address - Fax:207-443-5462
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME27671223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery