Provider Demographics
NPI:1366896466
Name:VICTORIA E. SHACK, DDS, PC
Entity type:Organization
Organization Name:VICTORIA E. SHACK, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:ELENA
Authorized Official - Last Name:SHACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-928-7500
Mailing Address - Street 1:3 MEDICAL DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1597
Mailing Address - Country:US
Mailing Address - Phone:631-928-7500
Mailing Address - Fax:
Practice Address - Street 1:3 MEDICAL DR
Practice Address - Street 2:SUITE D
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1597
Practice Address - Country:US
Practice Address - Phone:631-928-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056759122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty