Provider Demographics
NPI:1922239250
Name:CERVENKA, PETER (DMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:CERVENKA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PETER CERVENKA
Mailing Address - Street 2:4828 SEINE COURT
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455
Mailing Address - Country:US
Mailing Address - Phone:530-591-7813
Mailing Address - Fax:
Practice Address - Street 1:NMRTU DAM NECK MEDICAL ANNEX
Practice Address - Street 2:1885 TERRIER AVE., BLDG 504, RM. 125A
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23461
Practice Address - Country:US
Practice Address - Phone:757-953-9848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-04
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA04014164361223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program