Provider Demographics
NPI:1316922792
Name:STIME, VICTOR S (DDS)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:S
Last Name:STIME
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 1:21702 N PERRY RD
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:WA
Mailing Address - Zip Code:99005-9487
Mailing Address - Country:US
Mailing Address - Phone:509-468-2651
Mailing Address - Fax:509-466-6615
Practice Address - Street 1:34705 N NEWPORT HWY
Practice Address - Street 2:RIVERSIDE DENTAL CLINIC
Practice Address - City:CHATTAROY
Practice Address - State:WA
Practice Address - Zip Code:99003-7711
Practice Address - Country:US
Practice Address - Phone:509-292-2211
Practice Address - Fax:505-292-2209
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5004155Medicaid