Healthcare Provider Details

I. General information

NPI: 1982901997
Provider Name (Legal Business Name): THOMAS ELLIOTT VANDYKE PHD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2011
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 FIRST ST SUITE 1756
CAMBRIDGE MA
02142-1200
US

IV. Provider business mailing address

245 FIRST ST SUITE 1756
CAMBRIDGE MA
02142-1200
US

V. Phone/Fax

Practice location:
  • Phone: 617-892-8503
  • Fax: 617-262-4021
Mailing address:
  • Phone: 617-892-8503
  • Fax: 617-262-4021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN 18882
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: