Provider Demographics
NPI:1376571950
Name:DYKSTRA, DENNIS DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:DALE
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:420 DELAWARE STREET SE
Mailing Address - Street 2:MMC 297 UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-625-2661
Mailing Address - Fax:612-624-6686
Practice Address - Street 1:516 DELAWARE STREET SE
Practice Address - Street 2:PWB 1ST FL CLINIC 1A UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-626-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26055208000000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2T420DYOtherBCBS
MN23-24496OtherMEDICA CHOICE
MN075203700Medicaid
MN1009089OtherPREFERRED ONE
MN609344OtherARAZ
MN101455OtherUCARE
MN23-00008OtherMEDICA PRIMARY
MNHP22113OtherHEALTHPARTNERS
MN075203700Medicaid
MN609344OtherARAZ
MN2T420DYOtherBCBS