Healthcare Provider Details

I. General information

NPI: 1356601249
Provider Name (Legal Business Name): FIRST COAST ORAL & FACIAL SURGERY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2012
Last Update Date: 05/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 W TOWN PLACE SUITE 2
ST AUGUSTINE FL
32092
US

IV. Provider business mailing address

319 WEST TOWN PLACE #2
ST. AUGUSTINE FL
32092
US

V. Phone/Fax

Practice location:
  • Phone: 904-529-8889
  • Fax:
Mailing address:
  • Phone: 904-529-8889
  • Fax: 904-529-8893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS E STAKEM
Title or Position: PRESIDENT
Credential: D.D.S., M.D.
Phone: 904-529-8889