1417326869 NPI number — SAGE DENTAL OF PORT ST LUCIE PEDIATRIC & SPECIALTY CENTER PLLC

Table of content: (NPI 1417326869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417326869 NPI number — SAGE DENTAL OF PORT ST LUCIE PEDIATRIC & SPECIALTY CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAGE DENTAL OF PORT ST LUCIE PEDIATRIC & SPECIALTY CENTER PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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Provider's Other Name Information

Provider Other Organization Name:
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NPI Number Information

NPI Number:
1417326869
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
951 BROKEN SOUND PKWY
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33487-3507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-999-9650
Provider Business Mailing Address Fax Number:
561-431-8169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1660 SW SAINT LUCIE WEST BLVD
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34986-1967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-337-8388
Provider Business Practice Location Address Fax Number:
561-431-8169
Provider Enumeration Date:
09/16/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ZIEGLER
Authorized Official First Name:
NEAL
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF DENTAL DIRECTOR
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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