Basic Information
| Provider Information | |||||||||
| NPI: | 1215503206 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAGE DENTAL OF LAKELAND SOUTH PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 951 BROKEN SOUND PKWY NW STE 250 | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334873506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619999650 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4021 S FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338131623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619999650 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2021 | ||||||||
| LastUpdateDate: | 06/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | ROARK | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5619999650 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DMD, MS, COO | ||||||||
| NPICertificationDate: | 06/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.