Provider Demographics
NPI:1104028232
Name:JAN CERVENKA DMD INC
Entity Type:Organization
Organization Name:JAN CERVENKA DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CERVENKA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-737-5555
Mailing Address - Street 1:2212 POST RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1540
Mailing Address - Country:US
Mailing Address - Phone:401-737-5555
Mailing Address - Fax:
Practice Address - Street 1:2212 POST RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1540
Practice Address - Country:US
Practice Address - Phone:401-737-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI25641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty