Healthcare Provider Details

I. General information

NPI: 1093815029
Provider Name (Legal Business Name): SOUTHPARK DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8801 COMMODITY CIR
ORLANDO FL
32819-9053
US

IV. Provider business mailing address

8801 COMMODITY CIR
ORLANDO FL
32819-9053
US

V. Phone/Fax

Practice location:
  • Phone: 407-248-0100
  • Fax: 407-248-8364
Mailing address:
  • Phone: 407-248-0100
  • Fax: 407-248-8364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14090
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9168
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13762
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14238
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number16360
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12525
License Number StateFL

VIII. Authorized Official

Name: DR. JOHN F CERVENKA
Title or Position: OWNER
Credential: D.D.S.
Phone: 407-248-0100