=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154341204
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM ALBERT VAN DYK DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2089 VALE RD SUITE 30
-----------------------------------------------------
City | SAN PABLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94806-3847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-236-1662
-----------------------------------------------------
Fax | 510-236-5217
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2089 VALE RD SUITE 30
-----------------------------------------------------
City | SAN PABLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94806-3847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-236-1662
-----------------------------------------------------
Fax | 510-236-5217
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 23573
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------