Provider Demographics
NPI:1104340991
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:<UNAVAIL>
Other - Org Type:
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, MS
Authorized Official - Phone:386-986-1000
Mailing Address - Street 1:3 CYPRESS BRANCH WAY STE 107
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-8410
Mailing Address - Country:US
Mailing Address - Phone:386-986-1000
Mailing Address - Fax:386-446-1033
Practice Address - Street 1:3 CYPRESS BRANCH WAY STE 107
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-8410
Practice Address - Country:US
Practice Address - Phone:386-986-1000
Practice Address - Fax:386-446-1033
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
FLDN2016281223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty