Provider Demographics
NPI:1477661999
Name:DYKSTRA, JOHN T (DDS, PLLC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:DDS, PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N OLYMPIC AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223-1247
Mailing Address - Country:US
Mailing Address - Phone:360-435-4043
Mailing Address - Fax:360-435-2344
Practice Address - Street 1:520 N OLYMPIC AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-1247
Practice Address - Country:US
Practice Address - Phone:360-435-4043
Practice Address - Fax:360-435-2344
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA44871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5007497Medicaid
WA34-2005101OtherTIN