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General NPI Number Information
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NPI Number | 1164956157
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Entity Type | Organization
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Legal Business Name | SAGE DENTAL GROUP OF GEORGIA LLC
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Dates
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Enumeration Date | 04/17/2017
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Last Update Date | 05/18/2023
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Provider Practice Location Address
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Address Line | 4320 LAVISTA RD SUITE C119
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City | TUCKER
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State | GA
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Zip | 30084
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Country | US
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Telephone | 678-688-4811
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Fax | 561-431-8169
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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 | 678-688-4811
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Fax | 561-431-8169
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Authorized Official
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Title or Position | CHIEF DENTAL DIRECTOR
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Name | JONATHAN CHANG
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Credential | DMD
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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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