Provider Demographics
NPI:1417161555
Name:VANDYKE, JACK L (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:L
Last Name:VANDYKE
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:PO BOX 1970
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98674
Mailing Address - Country:US
Mailing Address - Phone:360-225-9494
Mailing Address - Fax:360-225-9495
Practice Address - Street 1:640 GEORIG ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:WA
Practice Address - Zip Code:98674
Practice Address - Country:US
Practice Address - Phone:360-225-9494
Practice Address - Fax:360-225-9495
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA4991122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist