Healthcare Provider Details

I. General information

NPI: 1295110302
Provider Name (Legal Business Name): SAGE DENTAL OF CONWAY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4441 HOFFNER AVE
BELLE ISLE FL
32812-2331
US

IV. Provider business mailing address

6600 CONGRESS AVE STE 150
BOCA RATON FL
33487-1213
US

V. Phone/Fax

Practice location:
  • Phone: 407-218-4744
  • Fax: 561-431-8169
Mailing address:
  • Phone: 561-999-9650
  • Fax: 561-431-8169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: ANTONIO CRUZ
Title or Position: CHIEF DENTAL DIRECTOR
Credential: DMD
Phone: 561-999-9650