MEDICARE: PROF. TAKASHI KOYAMA DMD, PHD FACS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DN16376	FL
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	DN16376	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DN 16376	OTHER	FL	MEDICAL LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356459028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PROF. TAKASHI KOYAMA DMD, PHD FACS

Provider Business Mailing Address
First Line	:	2402 FRIST BLVD STE 100
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-4838
Country	:	US
Telephone Number	:	772-461-9700
Fax Number	:	772-461-9300

Provider Business Practice Location Address
First Line	:	2402 FRIST BLVD STE 100
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-4838
Country	:	US
Telephone Number	:	772-461-9700
Fax Number	:	772-461-9300

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	07/16/2019

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