Provider Demographics
NPI:1457638629
Name:SAGE M. HUMPHRIES, DDS., MS., INC.
Entity Type:Organization
Organization Name:SAGE M. HUMPHRIES, DDS., MS., INC.
Other - Org Name:HUMPHRIES ORTHODONTICS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAGE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HUMPHRIES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:714-997-5961
Mailing Address - Street 1:725 W LA VETA AVE
Mailing Address - Street 2:STE 120
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4403
Mailing Address - Country:US
Mailing Address - Phone:714-997-5961
Mailing Address - Fax:714-997-9032
Practice Address - Street 1:18000 PIONEER BLVD
Practice Address - Street 2:STE 207
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-3976
Practice Address - Country:US
Practice Address - Phone:562-860-1333
Practice Address - Fax:562-860-2833
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HUMPHRIES ORTHODONTICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53072305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization