Provider Demographics
NPI:1205615580
Name:SAGE DENTAL OF BEACHWALK PLLC
Entity type:Organization
Organization Name:SAGE DENTAL OF BEACHWALK PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP & 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:PO BOX 931622
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-1622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:855 COUNTY ROAD 210 W STE A2-A3
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-1147
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:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty