Organization
TAKASHI KOYAMA DMD PHD PA
Active
Other names
Florida Institute of OMS
Organization subpart
No
Provider details
NPI number
Authorized official
TANYA GONZALEZ (PRACTICE MANAGER)
(772) 461-9700
Entity
Organization
Contact information
Practice address
2402 FRIST BLVD STE 100, FORT PIERCE, FL 34950-4838
(772) 461-9700
(772) 461-9300
Mailing address
2402 FRIST BLVD STE 100, FORT PIERCE, FL 34950-4838
(772) 461-9700
(772) 461-9300
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
—
—
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
DN 16376
MEDICAL LICENSE
FL
Enumeration date
12/04/2006
Last updated
01/31/2024
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