Provider Demographics
NPI:1023191038
Name:DELUKE, DEAN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEAN
Middle Name:M
Last Name:DELUKE
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 1:1070 NOTT ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12308-2410
Mailing Address - Country:US
Mailing Address - Phone:518-374-9109
Mailing Address - Fax:518-374-1978
Practice Address - Street 1:520 N 12TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5064
Practice Address - Country:US
Practice Address - Phone:804-628-6637
Practice Address - Fax:804-827-1040
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014132751223S0112X, 204E00000X
VA0438000293204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00711564Medicaid
NY190009682OtherRAILROAD MEDICARE