Provider Demographics
NPI:1093815029
Name:SOUTHPARK DENTAL GROUP
Entity Type:Organization
Organization Name:SOUTHPARK DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:CERVENKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:407-248-0100
Mailing Address - Street 1:8801 COMMODITY CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-9053
Mailing Address - Country:US
Mailing Address - Phone:407-248-0100
Mailing Address - Fax:407-248-8364
Practice Address - Street 1:8801 COMMODITY CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-9053
Practice Address - Country:US
Practice Address - Phone:407-248-0100
Practice Address - Fax:407-248-8364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14090122300000X
FL91681223G0001X
FL137621223G0001X
FL142381223G0001X
FL163601223G0001X
FL125251223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
836729OtherUNITED CONCORDIA