Provider Demographics
NPI:1861716573
Name:BUSTOS, VICTOR M (DMD, PL)
Entity type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:M
Last Name:BUSTOS
Suffix:
Gender:M
Credentials:DMD, PL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3112 W KENNEDY BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-3021
Mailing Address - Country:US
Mailing Address - Phone:813-874-5869
Mailing Address - Fax:813-874-5821
Practice Address - Street 1:3112 W KENNEDY BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3021
Practice Address - Country:US
Practice Address - Phone:813-874-5869
Practice Address - Fax:813-874-5821
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFB18281181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice