Provider Demographics
NPI:1629113808
Name:LIPOVETSKIY, BORIS (DMD)
Entity Type:Individual
Prefix:MR
First Name:BORIS
Middle Name:
Last Name:LIPOVETSKIY
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 1:104 SE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-1924
Mailing Address - Country:US
Mailing Address - Phone:954-525-5662
Mailing Address - Fax:954-525-5251
Practice Address - Street 1:104 SE 1ST ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-1924
Practice Address - Country:US
Practice Address - Phone:954-525-5662
Practice Address - Fax:954-525-5251
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA186451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0278238Medicaid