Provider Demographics
NPI:1689972473
Name:VICTORIA DENTAL PLLC
Entity Type:Organization
Organization Name:VICTORIA DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FATAKHOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-291-4232
Mailing Address - Street 1:9945 65TH RD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3118 STEINWAY ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3909
Practice Address - Country:US
Practice Address - Phone:718-728-7812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054434122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty