Provider Demographics
NPI:1629288824
Name:ST AUGUSTINE ORAL & FACIAL SURGICAL CENTER PA
Entity Type:Organization
Organization Name:ST AUGUSTINE ORAL & FACIAL SURGICAL CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-460-0505
Mailing Address - Street 1:PO BOX 7870
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72766-7870
Mailing Address - Country:US
Mailing Address - Phone:479-464-5824
Mailing Address - Fax:479-725-2395
Practice Address - Street 1:1301 PLANTATION ISLAND DR S
Practice Address - Street 2:SUITE 101
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3108
Practice Address - Country:US
Practice Address - Phone:904-460-0505
Practice Address - Fax:904-460-0506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN155681223S0112X, 204E00000X, 2082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDD5857OtherRAILROAD MEDICARE GROUP
FLK5486Medicare PIN
FLDD5857OtherRAILROAD MEDICARE GROUP