Fl Southern Dental Ppo PA

NPI #1841096799 in Lake Mary, Florida

Provider Information

NPI Number: 1841096799
Entity Type: Organization
Organization Name: Fl Southern Dental Ppo PA
Subpart: Yes (part of a larger organization)
Parent Organization: FL SOUTHERN DENTAL PPO PA
Primary Specialty: Dentist
Enumeration Date: Feb 21, 2025
Last Updated: Feb 21, 2025

Practice Location

Address: 4106 W LAKE MARY BLVD STE 230
City: Lake Mary
State: Florida
ZIP Code: 32746-2403
Phone: (407) 333-0881

Authorized Official

Name: ERIKA MELISSA MENJIVAR
Title: SR. CREDENTIALING SPECIALIST
Phone: (469) 596-6137

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Dentist	122300000X	Primary

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