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General NPI Number Information
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NPI Number | 1932623733
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Entity Type | Organization
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Legal Business Name | FLORIDA SEDATION, IMPLANT AND DENTAL SURGERY ASSOCIATES, LLC
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Dates
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Enumeration Date | 08/02/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 10 SAINT JOHNS MEDICAL PARK DR STE C
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32086-5202
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Country | US
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Telephone | 904-794-1000
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Fax | 904-794-1004
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Provider Business Mailing Address
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Address Line | 10 SAINT JOHNS MEDICAL PARK DR STE C
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32086-5202
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Country | US
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Telephone | 904-794-1000
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Fax | 904-794-1004
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Authorized Official
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Title or Position | OWNER
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Name | JOHN W THOUSAND IV
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Credential | D.D.S.
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Telephone | 904-794-1000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DN21628
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License Number State | FL
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