Provider Demographics
NPI:1932259405
Name:STAKEM, THOMAS E (DDS,MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:STAKEM
Suffix:
Gender:M
Credentials:DDS,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 SOPHIA TER
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-6839
Mailing Address - Country:US
Mailing Address - Phone:904-529-8889
Mailing Address - Fax:904-529-8893
Practice Address - Street 1:7175-01 U.S. HIGHWAY 17 SOUTH
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32095
Practice Address - Country:US
Practice Address - Phone:904-529-8889
Practice Address - Fax:904-529-8893
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN162221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery