Provider Demographics
NPI:1992573133
Name:VAN DYKE, MARIA TERASA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:TERASA
Last Name:VAN DYKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 PHILLIPS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45410-2638
Mailing Address - Country:US
Mailing Address - Phone:937-723-0112
Mailing Address - Fax:
Practice Address - Street 1:2269 S DIXIE DR
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45409-2018
Practice Address - Country:US
Practice Address - Phone:937-723-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251X00000X251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage