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General NPI Number Information
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NPI Number | 1932699592
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Entity Type | Organization
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Legal Business Name | SAGE DENTAL OF SODO PLLC
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Dates
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Enumeration Date | 05/18/2018
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Last Update Date | 05/18/2018
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Provider Practice Location Address
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Address Line | 1737 S ORANGE AVE
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City | ORLANDO
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State | FL
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Zip | 32806-2935
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Country | US
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Telephone | 407-341-1222
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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 STE 250
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City | BOCA RATON
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State | FL
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Zip | 33487-3506
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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 DIRECTOR
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | DN12876
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License Number State | FL
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