Provider Demographics
NPI:1790374320
Name:SAGE DENTAL OF WEST LAKE WORTH PLLC
Entity Type:Organization
Organization Name:SAGE DENTAL OF WEST LAKE WORTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-999-9650
Mailing Address - Street 1:951 BROKEN SOUND PKWY NW STE 250
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-3506
Mailing Address - Country:US
Mailing Address - Phone:561-999-9650
Mailing Address - Fax:
Practice Address - Street 1:7725 LAKE WORTH RD STE 7729
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-2536
Practice Address - Country:US
Practice Address - Phone:561-999-9650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty