Provider Demographics
NPI:1114459054
Name:SAGE DENTAL GROUP OF GEORGIA, LLC
Entity Type:Organization
Organization Name:SAGE DENTAL GROUP OF GEORGIA, LLC
Other - Org Name:SAGE DENTAL OF SUWANEE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF DENTAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-765-9133
Mailing Address - Street 1:6600 CONGRESS AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-1213
Mailing Address - Country:US
Mailing Address - Phone:678-765-9133
Mailing Address - Fax:561-431-8169
Practice Address - Street 1:3429 LAWRENCEVILLE SUWANEE RD
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-2433
Practice Address - Country:US
Practice Address - Phone:678-765-9133
Practice Address - Fax:561-431-8169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-30
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty