Provider Demographics
NPI:1437238516
Name:VICTOME, ROBERT GARY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GARY
Last Name:VICTOME
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 1:6137 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 1:6137 LAKE WORTH RD
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-3074
Practice Address - Country:US
Practice Address - Phone:561-357-1009
Practice Address - Fax:561-969-7624
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN137081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL650670857OtherTAX ID
FL076810300Medicaid