# FL SOUTHERN DENTAL PPO PA

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** FL SOUTHERN DENTAL PPO PA
- **Other names:** Hyde Park Center for Aesthetic Dentistry
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1598605081
- **Legal business name:** FL SOUTHERN DENTAL PPO PA
- **Authorized official:** ERIKA MELISSA MENJIVAR (SR. CREDENTIALING SPECIALIST)
- **Authorized official phone:** (469) 596-6137

## Contact information

- **Practice address:** 1407 W SWANN AVE, TAMPA, FL 33606-2532
- **Practice address phone:** (813) 251-1548
- **Mailing address:** 5830 GRANITE PKWY STE 780, PLANO, TX 75024-6775

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | — | NULL | Yes |
| 122300000X | Dentist | — | — | Yes |

## Other

- **Enumeration date:** 04/01/2026
- **Last updated:** 04/01/2026