Provider Demographics
NPI:1558700666
Name:VAN DYKE, DEREK (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:VAN DYKE
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 1:189 FOREST LAWN BLVD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-4370
Mailing Address - Country:US
Mailing Address - Phone:402-980-2972
Mailing Address - Fax:
Practice Address - Street 1:1190 INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6318
Practice Address - Country:US
Practice Address - Phone:740-382-5535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0240051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice