Provider Demographics
NPI:1013221811
Name:VAN DYKE DENTAL ASSOCIATES, PA
Entity Type:Organization
Organization Name:VAN DYKE DENTAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-744-6000
Mailing Address - Street 1:2621 RIDGEPOINT DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78754-5232
Mailing Address - Country:US
Mailing Address - Phone:512-744-6000
Mailing Address - Fax:512-334-2321
Practice Address - Street 1:2237 E RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-3051
Practice Address - Country:US
Practice Address - Phone:512-744-6000
Practice Address - Fax:512-334-2321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX231481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty