Healthcare Provider Details

I. General information

NPI: 1952584054
Provider Name (Legal Business Name): ALYSSA ANN DYKGRAAF DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5805 WHWY 22 STE 100
CRESTWOOD KY
40014
US

IV. Provider business mailing address

5805 W HWY 22 STE 100
CRESTWOOD KY
40014
US

V. Phone/Fax

Practice location:
  • Phone: 502-241-9407
  • Fax:
Mailing address:
  • Phone: 502-241-9407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1011495A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: