Provider Demographics
NPI:1356459028
Name:KOYAMA, TAKASHI (DMD, PHD FACS)
Entity Type:Individual
Prefix:PROF
First Name:TAKASHI
Middle Name:
Last Name:KOYAMA
Suffix:
Gender:M
Credentials:DMD, PHD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 FRIST BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4838
Mailing Address - Country:US
Mailing Address - Phone:772-461-9700
Mailing Address - Fax:772-461-9300
Practice Address - Street 1:2402 FRIST BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4838
Practice Address - Country:US
Practice Address - Phone:772-461-9700
Practice Address - Fax:772-461-9300
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN163761223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN 16376OtherMEDICAL LICENSE