Provider Demographics
NPI:1558429753
Name:TAKASHI KOYAMA DMD PHD PA
Entity Type:Organization
Organization Name:TAKASHI KOYAMA DMD PHD PA
Other - Org Name:FLORIDA INSTITUTE OF OMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-461-9700
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN 16376OtherMEDICAL LICENSE