Healthcare Provider Details

I. General information

NPI: 1558429753
Provider Name (Legal Business Name): TAKASHI KOYAMA DMD PHD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
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 Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: TANYA GONZALEZ
Title or Position: PRACTICE MANAGER
Credential:
Phone: 772-461-9700