Provider Demographics
NPI:1558567396
Name:VICTORINO, SHARLETTE NICOLE (DMD)
Entity Type:Individual
Prefix:
First Name:SHARLETTE
Middle Name:NICOLE
Last Name:VICTORINO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1693 STILLWATER AVE
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-3088
Mailing Address - Country:US
Mailing Address - Phone:859-576-6919
Mailing Address - Fax:
Practice Address - Street 1:8327 INDIANAPOLIS BLVD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-1065
Practice Address - Country:US
Practice Address - Phone:219-923-3886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN86651223G0001X
KY85891223G0001X
GA0144831223G0001X
IN12012074A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1223G0001XOtherEPSDT
KY1223G0001XMedicaid