Healthcare Provider Details

I. General information

NPI: 1487802096
Provider Name (Legal Business Name): RUFUS O. VAN DYKE, D.D.S., M.CL.D
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 BENCH RD SUITE A
POCATELLO ID
83201-5083
US

IV. Provider business mailing address

1455 BENCH RD SUITE A
POCATELLO ID
83201-5083
US

V. Phone/Fax

Practice location:
  • Phone: 208-237-3330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD-3206-OR
License Number StateID

VIII. Authorized Official

Name: TRACY VAN DYKE
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-237-3330