Provider Demographics
NPI:1487802096
Name:RUFUS O. VAN DYKE, D.D.S., M.CL.D
Entity type:Organization
Organization Name:RUFUS O. VAN DYKE, D.D.S., M.CL.D
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DYKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-237-3330
Mailing Address - Street 1:1455 BENCH RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5083
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1455 BENCH RD
Practice Address - Street 2:SUITE A
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5083
Practice Address - Country:US
Practice Address - Phone:208-237-3330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3206-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID9211318Medicaid