Provider Demographics
NPI:1932623733
Name:FLORIDA SEDATION, IMPLANT AND DENTAL SURGERY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:FLORIDA SEDATION, IMPLANT AND DENTAL SURGERY ASSOCIATES, LLC
Other - Org Name:DENTAL SPECIALISTS OF NORTH FLORIDA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:THOUSAND
Authorized Official - Suffix:IV
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-794-1000
Mailing Address - Street 1:10 SAINT JOHNS MEDICAL PARK DR STE C
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5202
Mailing Address - Country:US
Mailing Address - Phone:904-794-1000
Mailing Address - Fax:904-794-1004
Practice Address - Street 1:10 SAINT JOHNS MEDICAL PARK DR STE C
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5202
Practice Address - Country:US
Practice Address - Phone:904-794-1000
Practice Address - Fax:904-794-1004
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA SEDATION, IMPLANT AND DENTAL SURGERY ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN216281223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty