Basic Information
Provider Information
NPI: 1346593076
EntityType: 2
ReplacementNPI:  
OrganizationName: SAGE DENTAL OF PEMBROKE PINES, PLLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
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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: 17027 PINES BOULEVARD
Address2:  
City: PEMBROKE PINES
State: FL
PostalCode: 330271003
CountryCode: US
TelephoneNumber: 9547040044
FaxNumber: 5614318169
Other Information
ProviderEnumerationDate: 10/18/2012
LastUpdateDate: 03/17/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
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ProviderGenderCode:  
AuthorizedOfficialLastName: CRUZ
AuthorizedOfficialFirstName: ANTONIO
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CHIEF DENTAL DIRECTOR
AuthorizedOfficialTelephone: 5619999650
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: DDS
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000XDN6483FLY193200000X MULTI-SPECIALTY GROUPDental ProvidersDentist 

No ID Information.


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