MEDICARE: SAGE DENTAL OF ALAFAYA 2 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	:	1265211544
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAGE DENTAL OF ALAFAYA 2 PLLC

Provider Business Mailing Address
First Line	:	PO BOX 931622
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	31193-1622
Country	:	US
Telephone Number	:	561-999-9650
Fax Number	:

Provider Business Practice Location Address
First Line	:	12950 E COLONIAL DR STE 124
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32826-4609
Country	:	US
Telephone Number	:	561-999-9650
Fax Number	:

Authorized Official
Title or Position	:	SVP & CHIEF CLINICAL OFFICER
Name	:	CINDY ROARK
Credential	:
Telephone Number	:	561-999-9650

Provider Enumeration Date	:	09/26/2023
Last Update Date	:	09/26/2023

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