NPIMap

Organization Active NPI

FL Southern Dental PA

Doing business as Matanzas Dental Group

  • General Practice Dentistry
  • St Augustine, FL
National Provider Identifier
1265133185
Registry record updated Mar 17, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
Legal business name
FL SOUTHERN DENTAL PA
Doing business as
Matanzas Dental Group
Practice address
100 Whetstone PL Ste 308
St Augustine, FL 32086-5775
Phone
(904) 810-2345
NPI assigned
Mar 16, 2023
Last updated
Mar 17, 2026By the provider in NPPES
Organization subpart
Yes
Parent organization
FL SOUTHERN DENTAL PAAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 17, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Erika Melissa Menjivar
Title
Sr. Credentialing Specialist
Phone
(469) 596-6137

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193200000X MULTI-SPECIALTY GROUP 1223G0001X Primary

Addresses

Primary practice location

100 Whetstone PL Ste 308
St Augustine, FL 32086-5775

Mailing address

5830 Granite Pkwy Ste 780
Plano, TX 75024-6775
Phone (469) 596-6011

Other names 1

  • Matanzas Dental Group Doing business as

National Provider Directory

National Provider Directory
Tax ID family
FL Southern Dental PA2 organizations share this tax ID, including this one
Part of
FL Southern Dental PA

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

100 Whetstone Pl
Ste 308
St Augustine, FL 32086
Phone (904) 299-7997

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1678924800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1773705600000",
    "number": "1265133185",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5830 GRANITE PKWY STE 780",
            "city": "PLANO",
            "state": "TX",
            "postal_code": "750246775",
            "telephone_number": "469-596-6011"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 WHETSTONE PL STE 308",
            "city": "ST AUGUSTINE",
            "state": "FL",
            "postal_code": "320865775",
            "telephone_number": "904-810-2345"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FL SOUTHERN DENTAL PA",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "FL SOUTHERN DENTAL PA",
        "enumeration_date": "2023-03-16",
        "last_updated": "2026-03-17",
        "certification_date": "2026-03-17",
        "status": "A",
        "authorized_official_last_name": "MENJIVAR",
        "authorized_official_first_name": "ERIKA",
        "authorized_official_middle_name": "MELISSA",
        "authorized_official_title_or_position": "SR. CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "469-596-6137"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Matanzas Dental Group",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in St Augustine, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 17, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.