Provider Demographics
NPI:1780604702
Name:VAN DYKE, RUFUS III (DDS, MCLD)
Entity type:Individual
Prefix:DR
First Name:RUFUS
Middle Name:
Last Name:VAN DYKE
Suffix:III
Gender:M
Credentials:DDS, MCLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 BENCH ROAD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2443
Mailing Address - Country:US
Mailing Address - Phone:208-237-3330
Mailing Address - Fax:208-237-3347
Practice Address - Street 1:1501 BENCH RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2443
Practice Address - Country:US
Practice Address - Phone:208-237-3330
Practice Address - Fax:208-237-3347
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3206-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics