Provider Demographics
NPI:1417329772
Name:DYKSTRA, JOHN W (HIS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 WASHINGTON AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4238
Mailing Address - Country:US
Mailing Address - Phone:262-637-5668
Mailing Address - Fax:262-637-5009
Practice Address - Street 1:3333 S SUNNYSLOPE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4502
Practice Address - Country:US
Practice Address - Phone:262-784-0236
Practice Address - Fax:262-784-0237
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1287237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist