Basic Information
Provider Information | |||||||||
NPI: | 1417481599 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAGE DENTAL GROUP OF GEORGIA LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAGE DENTAL OF MARIETTA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1050 E PIEDMONT RD | ||||||||
Address2: | SUITE 114-118 | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300624758 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6785404665 | ||||||||
FaxNumber: | 5614318169 | ||||||||
Practice Location | |||||||||
Address1: | 1050 E PIEDMONT RD | ||||||||
Address2: | SUITE 114-118 | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300624758 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6787654665 | ||||||||
FaxNumber: | 5614318169 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2017 | ||||||||
LastUpdateDate: | 02/20/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHANG | ||||||||
AuthorizedOfficialFirstName: | JONATHAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF DENTAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5619999650 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DMD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   |
No ID Information.