Provider Demographics
NPI:1841228137
Name:LIPTON, JACK I (DMD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:I
Last Name:LIPTON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:I
Other - Last Name:LIPTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1754 S FORT APACHE RD # 1
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-6909
Mailing Address - Country:US
Mailing Address - Phone:480-329-6684
Mailing Address - Fax:
Practice Address - Street 1:1754 S FORT APACHE RD # 1
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-6909
Practice Address - Country:US
Practice Address - Phone:480-329-6684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60861122300000X
AZD43751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA60861OtherDENTAL LICENSE