Provider Demographics
NPI:1568813020
Name:VAN DYKE, JORDAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:VAN DYKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4514 ENVIRON WAY
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-4455
Mailing Address - Country:US
Mailing Address - Phone:919-265-3439
Mailing Address - Fax:
Practice Address - Street 1:4514 ENVIRON WAY
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-4455
Practice Address - Country:US
Practice Address - Phone:919-265-3439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice