Provider Demographics
NPI:1932291382
Name:VAN DYCK, LARRY EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:EDWARD
Last Name:VAN DYCK
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 1:460 S HOLLY ST
Mailing Address - Street 2:PO BOX 40
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-3018
Mailing Address - Country:US
Mailing Address - Phone:479-524-0333
Mailing Address - Fax:479-524-0378
Practice Address - Street 1:460 S HOLLY ST
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-3018
Practice Address - Country:US
Practice Address - Phone:479-524-0333
Practice Address - Fax:479-524-0378
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3939122300000X
OK5246122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist