Provider Demographics
NPI:1932117991
Name:LIPP, WALLACE J (DDS)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:J
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 1:16605 DEVONSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344
Mailing Address - Country:US
Mailing Address - Phone:818-366-4867
Mailing Address - Fax:818-366-7964
Practice Address - Street 1:16605 DEVONSHIRE ST
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344
Practice Address - Country:US
Practice Address - Phone:818-366-4867
Practice Address - Fax:818-366-7964
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16572122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist