Provider Demographics
NPI:1356601249
Name:FIRST COAST ORAL & FACIAL SURGERY, PA
Entity type:Organization
Organization Name:FIRST COAST ORAL & FACIAL SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:STAKEM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:904-529-8889
Mailing Address - Street 1:319 WEST TOWN PLACE #2
Mailing Address - Street 2:
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092
Mailing Address - Country:US
Mailing Address - Phone:904-529-8889
Mailing Address - Fax:904-529-8893
Practice Address - Street 1:319 W TOWN PLACE
Practice Address - Street 2:SUITE 2
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092
Practice Address - Country:US
Practice Address - Phone:904-529-8889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty