Healthcare Provider Details

I. General information

NPI: 1194746727
Provider Name (Legal Business Name): WILLIAM ALBERT DYKES JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VA MEDICAL CENTER PO 4000
MOUNTAIN HOME TN
37684
US

IV. Provider business mailing address

1201 BUFFALO ST APT #4
JOHNSON CITY TN
37604-6772
US

V. Phone/Fax

Practice location:
  • Phone: 423-926-1171
  • Fax:
Mailing address:
  • Phone: 423-794-0549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD.S. 1915
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: