Provider Demographics
NPI:1801969399
Name:CERVENKA, JAN R (DMD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:R
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 1:2212 POST ROAD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886
Mailing Address - Country:US
Mailing Address - Phone:401-737-5555
Mailing Address - Fax:401-738-6649
Practice Address - Street 1:2212 POST ROAD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886
Practice Address - Country:US
Practice Address - Phone:401-737-5555
Practice Address - Fax:401-738-6649
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI25641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice