Healthcare Provider Details

I. General information

NPI: 1629200423
Provider Name (Legal Business Name): JEFFREY JAMES STYSKAL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 08/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 FISHER ST
KEESLER AFB MS
39534-2513
US

IV. Provider business mailing address

606 FISHER ST
KEESLER AFB MS
39534-2513
US

V. Phone/Fax

Practice location:
  • Phone: 228-376-0511
  • Fax:
Mailing address:
  • Phone: 228-376-0511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7853
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: