Healthcare Provider Details

I. General information

NPI: 1356459028
Provider Name (Legal Business Name): TAKASHI KOYAMA DMD, PHD FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 FRIST BLVD STE 100
FORT PIERCE FL
34950-4838
US

IV. Provider business mailing address

2402 FRIST BLVD STE 100
FORT PIERCE FL
34950-4838
US

V. Phone/Fax

Practice location:
  • Phone: 772-461-9700
  • Fax: 772-461-9300
Mailing address:
  • Phone: 772-461-9700
  • Fax: 772-461-9300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN16376
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDN16376
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: