1144419755 NPI number — DR. OSBORNE JEFFERSON DYKES IV DDS, MS

Table of content: DR. OSBORNE JEFFERSON DYKES IV DDS, MS (NPI 1144419755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144419755 NPI number — DR. OSBORNE JEFFERSON DYKES IV DDS, MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DYKES
Provider First Name:
OSBORNE
Provider Middle Name:
JEFFERSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
IV
Provider Credential Text:
DDS, MS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DYKES
Provider Other First Name:
JEFF
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS, MS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1144419755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1007 RR 620 S
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
LAKEWAY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78734-5634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-633-7056
Provider Business Mailing Address Fax Number:
512-351-9829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1007 RR 620 S
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
LAKEWAY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78734-5634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-263-2993
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  22118 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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