MEDICARE: SAGE DENTAL OF LAKE WORTH, P.A.

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	1223G0001X	General Practice Dentistry	DN6483	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316142037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAGE DENTAL OF LAKE WORTH, P.A.

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

Provider Business Practice Location Address
First Line	:	1922 LAKE WORTH RD
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-4228
Country	:	US
Telephone Number	:	561-547-5597
Fax Number	:	561-431-8169

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

Provider Enumeration Date	:	06/21/2007
Last Update Date	:	03/17/2017

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