Healthcare Provider Details

I. General information

NPI: 1144419755
Provider Name (Legal Business Name): OSBORNE JEFFERSON DYKES IV DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JEFF DYKES DDS, MS

II. Dates (important events)

Enumeration Date: 10/19/2007
Last Update Date: 09/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 RR 620 S SUITE 201
LAKEWAY TX
78734-5634
US

IV. Provider business mailing address

1007 RR 620 S SUITE 201
LAKEWAY TX
78734-5634
US

V. Phone/Fax

Practice location:
  • Phone: 512-263-2993
  • Fax:
Mailing address:
  • Phone: 512-633-7056
  • Fax: 512-351-9829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22118
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: