Provider Demographics
NPI:1932699592
Name:SAGE DENTAL OF SODO PLLC
Entity Type:Organization
Organization Name:SAGE DENTAL OF SODO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF DENTAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-999-9650
Mailing Address - Street 1:951 BROKEN SOUND PKWY 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:561-431-8169
Practice Address - Street 1:1737 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2935
Practice Address - Country:US
Practice Address - Phone:407-341-1222
Practice Address - Fax:561-431-8169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN12876122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty