=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114416112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMES TAGONI DMD MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2018
-----------------------------------------------------
Last Update Date | 05/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1309 THOMASVILLE RD
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32303-5607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-252-8928
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2300 BLUFF OAK WAY APT 5303
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32311-6131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-252-8928
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORAL & MAXILLOFACIAL SURGEON
-----------------------------------------------------
Name | JAMES ROBERT TAGONI
-----------------------------------------------------
Credential | DMD, MD
-----------------------------------------------------
Telephone | 805-252-8928
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------