Provider Demographics
NPI:1972990752
Name:THOUSAND, JOHN WILLAIM IV (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLAIM
Last Name:THOUSAND
Suffix:IV
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 WINDWARD WAY
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6182
Mailing Address - Country:US
Mailing Address - Phone:303-250-4091
Mailing Address - Fax:
Practice Address - Street 1:3 CYPRESS BRANCH WAY
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-8409
Practice Address - Country:US
Practice Address - Phone:386-445-4247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002018691223P0300X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics