=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366896466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VICTORIA E. SHACK, DDS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2016
-----------------------------------------------------
Last Update Date | 04/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 MEDICAL DR SUITE D
-----------------------------------------------------
City | PORT JEFFERSON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11776-1597
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-928-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 MEDICAL DR SUITE D
-----------------------------------------------------
City | PORT JEFFERSON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11776-1597
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-928-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. VICTORIA ELENA SHACK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 631-928-7500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 056759
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------