Provider Demographics
NPI:1194894071
Name:CANESTRARO, VICTOR R (DDS)
Entity type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:R
Last Name:CANESTRARO
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:RR 1 BOX 72C
Mailing Address - Street 2:
Mailing Address - City:VALLEY GROVE
Mailing Address - State:WV
Mailing Address - Zip Code:26060-8901
Mailing Address - Country:US
Mailing Address - Phone:304-547-0653
Mailing Address - Fax:
Practice Address - Street 1:1052 E BETHLEHEM BLVD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-4961
Practice Address - Country:US
Practice Address - Phone:304-233-1244
Practice Address - Fax:304-233-1248
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV35771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000474Medicaid