Organization
FL SOUTHERN DENTAL PPO PA
Active
Parent organization
FL SOUTHERN DENTAL PPO PA
Other names
Northdale-Dental Health Services
Organization subpart
Yes
Provider details
NPI number
Legal business name
FL SOUTHERN DENTAL PPO PA
Authorized official
ERIKA MELISSA MENJIVAR (SR. CREDENTIALING SPECIALIST)
(469) 596-6137
Entity
Organization
Contact information
Practice address
3910 NORTHDALE BLVD STE 102A, TAMPA, FL 33624-1800
(813) 969-0294
Mailing address
5830 GRANITE PKWY STE 780, PLANO, TX 75024-6775
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
—
—
Other
Enumeration date
04/01/2026
Last updated
04/01/2026
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