Basic Information
| Provider Information | |||||||||
| NPI: | 1508398447 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAGE DENTAL GROUP OF GEORGIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3420 BUFORD DR STE E780 | ||||||||
| Address2: | |||||||||
| City: | BUFORD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305198774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6787659930 | ||||||||
| FaxNumber: | 5614318169 | ||||||||
| Practice Location | |||||||||
| Address1: | 3410 BUFORD DR | ||||||||
| Address2: | E-780 | ||||||||
| City: | BUFORD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305194900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6787659930 | ||||||||
| FaxNumber: | 5614318169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2017 | ||||||||
| LastUpdateDate: | 02/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | CHANG | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF DENTAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6787659930 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.