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General NPI Number Information
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NPI Number | 1700034600
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Entity Type | Organization
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Legal Business Name | SAGE DENTAL OF COCONUT CREEK , PLLC
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Dates
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Enumeration Date | 09/04/2008
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Last Update Date | 02/24/2017
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Provider Practice Location Address
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Address Line | 5463 LYONS RD SUITE C
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City | COCONUT CREEK
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State | FL
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Zip | 33073-2828
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Country | US
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Telephone | 954-571-7123
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Fax | 561-431-8169
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Provider Business Mailing Address
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Address Line | 951 BROKEN SOUND PKWY SUITE 250
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City | BOCA RATON
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State | FL
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Zip | 33487
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Country | US
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Telephone | 561-999-9650
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Fax | 561-431-8169
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Authorized Official
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Title or Position | CHIEF DENTAL DIRECTORS
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Name | ANTONIO CRUZ
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN6483
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License Number State | FL
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