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General NPI Number Information
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NPI Number | 1093815029
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Entity Type | Organization
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Legal Business Name | SOUTHPARK DENTAL GROUP
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Dates
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Enumeration Date | 09/22/2006
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 8801 COMMODITY CIR
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City | ORLANDO
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State | FL
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Zip | 32819-9053
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Country | US
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Telephone | 407-248-0100
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Fax | 407-248-8364
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Provider Business Mailing Address
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Address Line | 8801 COMMODITY CIR
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City | ORLANDO
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State | FL
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Zip | 32819-9053
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Country | US
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Telephone | 407-248-0100
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Fax | 407-248-8364
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN F CERVENKA
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Credential | D.D.S.
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Telephone | 407-248-0100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 9168
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 13762
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 14238
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 16360
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License Number State | FL
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Taxonomy #5
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 12525
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License Number State | FL
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Taxonomy #6
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 14090
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License Number State | FL
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