Healthcare Provider Details

I. General information

NPI: 1568457620
Provider Name (Legal Business Name): JANA NMN DYKES DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 3865
APO AE
09126
DE

IV. Provider business mailing address

UNIT 3865
APO AE
09126
DE

V. Phone/Fax

Practice location:
  • Phone: 4-965-6169
  • Fax:
Mailing address:
  • Phone: 4-965-6169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4939
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: