Provider Demographics
NPI:1992567309
Name:SAGE DENTAL KIDS OF NEW TAMPA, PLLC
Entity type:Organization
Organization Name:SAGE DENTAL KIDS OF NEW TAMPA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP & CHIEF CLINICAL OFFICER
Authorized Official - Prefix:DR
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 1:10317 CROSS CREEK BLVD STE B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2845
Practice Address - Country:US
Practice Address - Phone:813-973-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-30
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty