Provider Demographics
NPI:1033774757
Name:VICTORIAN DENTAL
Entity Type:Organization
Organization Name:VICTORIAN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:HAMILTON
Authorized Official - Last Name:RAE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:386-624-7658
Mailing Address - Street 1:1431 ORANGE CAMP RD STE 108
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-7769
Mailing Address - Country:US
Mailing Address - Phone:386-624-7658
Mailing Address - Fax:386-873-4625
Practice Address - Street 1:131 VICTORIA COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724
Practice Address - Country:US
Practice Address - Phone:386-624-7658
Practice Address - Fax:386-873-4625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-08
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental