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General NPI Number Information
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NPI Number | 1972990752
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Entity Type | Individual
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Provider Name | JOHN WILLAIM THOUSAND IV D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 04/20/2015
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Last Update Date | 02/25/2016
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Provider Practice Location Address
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Address Line | 3 CYPRESS BRANCH WAY
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City | PALM COAST
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State | FL
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Zip | 32164-8409
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Country | US
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Telephone | 386-445-4247
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Fax |
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Provider Business Mailing Address
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Address Line | 980 WINDWARD WAY
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City | ST AUGUSTINE
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State | FL
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Zip | 32080-6182
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Country | US
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Telephone | 303-250-4091
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 00201869
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License Number State | CO
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