Active NPI
FL Southern Dental PPO PA
Doing business as Dental Lake Mary
- Dentist
- Lake Mary, FL
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- Legal business name
- FL SOUTHERN DENTAL PPO PA
- Doing business as
- Dental Lake Mary
- Practice address
- 4106 W Lake Mary Blvd Ste 230
Lake Mary, FL 32746-2403 - Phone
- (407) 333-0881
- NPI assigned
- Feb 21, 2025
- Organization subpart
- Yes
- Parent organization
- FL SOUTHERN DENTAL PPO PA
NPPES NPI Registry
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) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | Primary |
Addresses
Primary practice location
4106 W Lake Mary Blvd Ste 230
Lake Mary, FL 32746-2403
Mailing address
5830 Granite Pkwy Ste 780
Plano, TX 75024-6775
Other names 1
- Dental Lake Mary
National Provider Directory
National Provider Directory- Tax ID family
- FL Southern Dental PPO PA
- Part of
- FL Southern Dental PPO PA
Other organizations with this tax ID 9
Organizations that report the same tax identification number in the National Provider Directory.
-
dba Hyde Park Center for Aesthetic Dentistry
- Dentist
- Tampa, FL
- NPI 1598605081
Locations
4106 W Lake Mary Blvd
Ste 230
Lake Mary, FL 32746
Phone (407) 333-0881
Practitioners & affiliated clinicians
Practitioners 1
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.
-
- Dentist
- Lake Mary, FL
- NPI 1023106333
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1740096000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1740096000000",
"number": "1841096799",
"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"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4106 W LAKE MARY BLVD STE 230",
"city": "LAKE MARY",
"state": "FL",
"postal_code": "327462403",
"telephone_number": "407-333-0881"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "FL SOUTHERN DENTAL PPO PA",
"organizational_subpart": "YES",
"parent_organization_legal_business_name": "FL SOUTHERN DENTAL PPO PA",
"enumeration_date": "2025-02-21",
"last_updated": "2025-02-21",
"certification_date": "2025-02-21",
"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": "122300000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Dentist",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"organization_name": "Dental Lake Mary",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Lake Mary, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 21, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.