MEDICARE: SAGE DENTAL OF LAKE MARY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1043674872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAGE DENTAL OF LAKE MARY PLLC

Provider Business Mailing Address
First Line	:	951 BROKEN SOUND PKWY
Second Line	:	SUITE 250
City	:	BOCA RATON
State	:	FL
Zip	:	33487-3507
Country	:	US
Telephone Number	:	561-999-9650
Fax Number	:	561-431-8169

Provider Business Practice Location Address
First Line	:	3801 W LAKE MARY BLVD
Second Line	:	SUITE 111
City	:	LAKE MARY
State	:	FL
Zip	:	32746-6159
Country	:	US
Telephone Number	:	407-936-3400
Fax Number	:	561-431-8169

Authorized Official
Title or Position	:	CHIEF DENTAL DIRECTOR
Name	:	ANTONIO CRUZ
Credential	:	DMD
Telephone Number	:	561-999-9650

Provider Enumeration Date	:	04/07/2016
Last Update Date	:	04/19/2017

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