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General NPI Number Information
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NPI Number | 1346798063
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Entity Type | Organization
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Legal Business Name | MIL-LAKE DENTAL
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Dates
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Enumeration Date | 09/12/2016
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Last Update Date | 10/20/2016
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Provider Practice Location Address
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Address Line | 7657 LAKE WORTH RD
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City | LAKE WORTH
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State | FL
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Zip | 33467-2534
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Country | US
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Telephone | 561-357-1009
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Fax | 561-969-7624
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Provider Business Mailing Address
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Address Line | 6137 LAKE WORTH RD
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City | GREENACRES
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State | FL
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Zip | 33463-3074
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Country | US
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Telephone | 561-357-1009
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Fax | 561-969-7624
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Authorized Official
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Title or Position | OWNER
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Name | DR. ROBERT G. VICTOME
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Credential | DDS
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Telephone | 561-357-1009
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN13708
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number |
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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