1548676604 NPI number — SAGE DENTAL OF WINTER PARK PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548676604 NPI number — SAGE DENTAL OF WINTER PARK PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAGE DENTAL OF WINTER PARK PLLC
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:
1548676604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2017
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:
110 S ORLANDO AVE
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
WINTER PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32789-3613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-691-3347
Provider Business Practice Location Address Fax Number:
561-431-8169
Provider Enumeration Date:
07/09/2014

Additional Information

Authorized Official

Authorized Official Last Name:
CRUZ
Authorized Official First Name:
ANTONIO
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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