Provider Demographics
NPI:1588309165
Name:SAGE DENTAL OF BRANDON 2 PLLC
Entity type:Organization
Organization Name:SAGE DENTAL OF BRANDON 2 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:DMD, MS
Authorized Official - Phone:561-999-9650
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:561-999-9650
Mailing Address - Fax:561-431-2279
Practice Address - Street 1:2114 W BRANDON BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4704
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:2022-04-28
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty