Provider Demographics
NPI:1114961620
Name:VAN DYKE, LARELL C (DDS)
Entity Type:Individual
Prefix:
First Name:LARELL
Middle Name:C
Last Name:VAN DYKE
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:PO BOX 1079
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-1079
Mailing Address - Country:US
Mailing Address - Phone:801-785-7024
Mailing Address - Fax:
Practice Address - Street 1:610 LOADER DR
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-3116
Practice Address - Country:US
Practice Address - Phone:801-785-7024
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT133101-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice