1063251874 NPI number — SAGE DENTAL OF FORT MYERS AT ALICO COMMONS

Table of content: COURTNEY ALANA HAYASHI VICKERY MD (NPI 1023339348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063251874 NPI number — SAGE DENTAL OF FORT MYERS AT ALICO COMMONS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAGE DENTAL OF FORT MYERS AT ALICO COMMONS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063251874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6600 CONGRESS AVE STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33487-1213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-999-9650
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16960 ALICO MISSION WAY STE 100-101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33908-4844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-999-9650
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/21/2024

Additional Information

Authorized Official

Authorized Official Last Name:
ROARK
Authorized Official First Name:
CINDY
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP & CHIEF CLINICAL OFFICER
Authorized Official Telephone Number:
561-999-9650

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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