Healthcare Provider Details

I. General information

NPI: 1518097427
Provider Name (Legal Business Name): ROBERT R. THOUSAND III D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SAINT JOHNS MEDICAL PK DR STE. C
SAINT AUGUSTINE FL
32086-5201
US

IV. Provider business mailing address

10 ST. JOHNS MEDICAL PARK DRIVE SUITE C
ST. AUGUSTINE FL
32086
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-3044
  • Fax: 904-797-3045
Mailing address:
  • Phone: 904-797-3044
  • Fax: 904-797-3045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN 14671
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: