MEDICARE: SAGE DENTAL KIDS OF NEW TAMPA, 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	:	1992567309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAGE DENTAL KIDS OF NEW TAMPA, PLLC

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

Provider Business Practice Location Address
First Line	:	10317 CROSS CREEK BLVD STE B
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-2845
Country	:	US
Telephone Number	:	813-973-3100
Fax Number	:

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

Provider Enumeration Date	:	01/30/2024
Last Update Date	:	03/13/2024

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