Healthcare Provider Details

I. General information

NPI: 1710103486
Provider Name (Legal Business Name): SAGE MONROE HUMPHRIES D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 11/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 W LA VETA AVE STE 120
ORANGE CA
92868-4445
US

IV. Provider business mailing address

725 W LA VETA AVE STE 120
ORANGE CA
92868-4445
US

V. Phone/Fax

Practice location:
  • Phone: 714-997-5961
  • Fax:
Mailing address:
  • Phone: 714-997-5961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number53072
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number53072
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: