Provider Demographics
NPI:1093156002
Name:DYKSTRA, ALISA S (RDH)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:S
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:ALISA
Other - Middle Name:S
Other - Last Name:HENKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:782 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CHAPPELL
Mailing Address - State:NE
Mailing Address - Zip Code:69129-6891
Mailing Address - Country:US
Mailing Address - Phone:308-874-2203
Mailing Address - Fax:
Practice Address - Street 1:700 COLUMBINE ST
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:CO
Practice Address - Zip Code:80751-3728
Practice Address - Country:US
Practice Address - Phone:970-474-2619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO903692124Q00000X
KS10216124Q00000X
NE1454124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist