MEDICARE: FL SOUTHERN DENTAL PPO PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1295524825
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FL SOUTHERN DENTAL PPO PA

Provider Business Mailing Address
First Line	:	5830 GRANITE PKWY STE 780
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75024-6775
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	925 ARTHUR GODFREY RD STE 302
Second Line	:
City	:	MIAMI BEACH
State	:	FL
Zip	:	33140-3339
Country	:	US
Telephone Number	:	786-207-3179
Fax Number	:

Authorized Official
Title or Position	:	SR. CREDENTIALING SPECIALIST
Name	:	ERIKA MELISSA MENJIVAR
Credential	:
Telephone Number	:	469-596-6137

Provider Enumeration Date	:	05/01/2025
Last Update Date	:	05/01/2025

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