Provider Demographics
NPI:1063864270
Name:VAN DYKE, JONATHAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:VAN DYKE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 BALD EAGLE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MARCO ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34145-2731
Mailing Address - Country:US
Mailing Address - Phone:239-394-1004
Mailing Address - Fax:
Practice Address - Street 1:606 BALD EAGLE DR STE 200
Practice Address - Street 2:
Practice Address - City:MARCO ISLAND
Practice Address - State:FL
Practice Address - Zip Code:34145-2731
Practice Address - Country:US
Practice Address - Phone:239-394-1004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN22095122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist