Provider Demographics
NPI:1538427802
Name:SHACK, VICTORIA ELENA (DDS)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ELENA
Last Name:SHACK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N COUNTRY RD
Mailing Address - Street 2:APT A10
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2154
Mailing Address - Country:US
Mailing Address - Phone:917-324-7927
Mailing Address - Fax:
Practice Address - Street 1:150 N COUNTRY RD
Practice Address - Street 2:APT A10
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2154
Practice Address - Country:US
Practice Address - Phone:917-324-7927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056759-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice