Provider Demographics
NPI:1811036650
Name:DUTKO, VICTOR MARTIN JR (DDS)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:MARTIN
Last Name:DUTKO
Suffix:JR
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 1:2959 CANFIELD RD
Mailing Address - Street 2:SUITE 14
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-2800
Mailing Address - Country:US
Mailing Address - Phone:330-799-1216
Mailing Address - Fax:330-799-1526
Practice Address - Street 1:2959 CANFIELD RD
Practice Address - Street 2:SUITE 14
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44511-2800
Practice Address - Country:US
Practice Address - Phone:330-799-1216
Practice Address - Fax:330-799-1526
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH176501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0602235Medicaid