MEDICARE: SAGE DENTAL OF FORT MYERS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1316608722
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAGE DENTAL OF FORT MYERS PLLC

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

Provider Business Practice Location Address
First Line	:	8004 SUMMERLIN LAKES DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1817
Country	:	US
Telephone Number	:	239-267-7385
Fax Number	:

Authorized Official
Title or Position	:	SVP & CHIEF CLINICAL OFFICER
Name	:	CINDY ROARK
Credential	:	DMD, MS
Telephone Number	:	561-999-9650

Provider Enumeration Date	:	01/07/2022
Last Update Date	:	05/19/2023

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