Provider Demographics
NPI:1124424908
Name:DYKSTRA, MICHAEL HENRY (RT (R))
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:HENRY
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:RT (R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5314 BANNON CROSSINGS DR
Mailing Address - Street 2:
Mailing Address - City:BUECHEL
Mailing Address - State:KY
Mailing Address - Zip Code:40218-4023
Mailing Address - Country:US
Mailing Address - Phone:502-320-7456
Mailing Address - Fax:
Practice Address - Street 1:5314 BANNON CROSSINGS DR
Practice Address - Street 2:
Practice Address - City:BUECHEL
Practice Address - State:KY
Practice Address - Zip Code:40218-4023
Practice Address - Country:US
Practice Address - Phone:502-320-7456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10-056-108602471C3402X
MN4731242471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography