Provider Demographics
NPI:1346798063
Name:MIL-LAKE DENTAL
Entity Type:Organization
Organization Name:MIL-LAKE DENTAL
Other - Org Name:MIL-LAKE DENTAL AND EYE CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:VICTOME
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-357-1009
Mailing Address - Street 1:6137 LAKE WORTH RD
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-3074
Mailing Address - Country:US
Mailing Address - Phone:561-357-1009
Mailing Address - Fax:561-969-7624
Practice Address - Street 1:7657 LAKE WORTH RD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-2534
Practice Address - Country:US
Practice Address - Phone:561-357-1009
Practice Address - Fax:561-969-7624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-12
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13708122300000X
152W00000X, 207W00000X, 208D00000X
FL156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty