1487191649 NPI number — SAGE DENTAL GROUP OF GEORGIA, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487191649 NPI number — SAGE DENTAL GROUP OF GEORGIA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAGE DENTAL GROUP OF GEORGIA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487191649
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6600 CONGRESS AVE STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33487-1213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-847-7690
Provider Business Mailing Address Fax Number:
561-431-8169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11160 MEDLOCK BRIDGE RD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30097-2590
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-847-7690
Provider Business Practice Location Address Fax Number:
561-431-8169
Provider Enumeration Date:
01/26/2017

Additional Information

Authorized Official

Authorized Official Last Name:
CHANG
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF DENTAL DIRECTOR
Authorized Official Telephone Number:
561-999-9650

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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