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General NPI Number Information
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NPI Number | 1063251874
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Entity Type | Organization
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Legal Business Name | SAGE DENTAL OF FORT MYERS AT ALICO COMMONS
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Dates
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Enumeration Date | 05/21/2024
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Last Update Date | 05/21/2024
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Provider Practice Location Address
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Address Line | 16960 ALICO MISSION WAY STE 100-101
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City | FORT MYERS
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State | FL
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Zip | 33908-4844
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Country | US
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Telephone | 561-999-9650
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Fax |
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Provider Business Mailing Address
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Address Line | 6600 CONGRESS AVE STE 150
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City | BOCA RATON
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State | FL
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Zip | 33487-1213
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Country | US
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Telephone | 561-999-9650
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Fax |
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Authorized Official
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Title or Position | SVP & CHIEF CLINICAL OFFICER
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Name | CINDY ROARK
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Credential |
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Telephone | 561-999-9650
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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