Provider Demographics
NPI:1396384210
Name:DYKSTRA, COOPER (DC)
Entity Type:Individual
Prefix:DR
First Name:COOPER
Middle Name:
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 W RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-1105
Mailing Address - Country:US
Mailing Address - Phone:605-799-7579
Mailing Address - Fax:
Practice Address - Street 1:2221 W RUSSELL ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-1105
Practice Address - Country:US
Practice Address - Phone:605-799-7579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-23
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6630111N00000X
SD1375111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor