Healthcare Provider Details

I. General information

NPI: 1669145710
Provider Name (Legal Business Name): SAGE DENTAL OF SAINT CLOUD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 13TH ST
SAINT CLOUD FL
34769-6722
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 561-999-9650
  • Fax:
Mailing address:
  • Phone: 561-999-9650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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