MEDICARE: DR. BRADLEY ALAN DYKSTRA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2901011799	MI

General Provider Information

NPI Number	:	1912117128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY ALAN DYKSTRA DDS

Provider Business Mailing Address
First Line	:	3250 CENTRAL BLVD
Second Line	:
City	:	HUDSONVILLE
State	:	MI
Zip	:	49426-1439
Country	:	US
Telephone Number	:	616-669-6600
Fax Number	:

Provider Business Practice Location Address
First Line	:	3250 CENTRAL BLVD
Second Line	:
City	:	HUDSONVILLE
State	:	MI
Zip	:	49426-1439
Country	:	US
Telephone Number	:	616-669-6600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	07/08/2007

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