Basic Information
| Provider Information | |||||||||
| NPI: | 1205193539 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAGE DENTAL OF PORT ST LUCIE WEST, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 951 BROKEN SOUND PKWY | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619999650 | ||||||||
| FaxNumber: | 5614318169 | ||||||||
| Practice Location | |||||||||
| Address1: | 1722 SW SAINT LUCIE WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349862504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723378600 | ||||||||
| FaxNumber: | 5614318169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2012 | ||||||||
| LastUpdateDate: | 04/19/2017 | ||||||||
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| AuthorizedOfficialLastName: | CRUZ | ||||||||
| AuthorizedOfficialFirstName: | ANTONIO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF DENTAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5619999650 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DN6483 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.