Provider Demographics
NPI:1093111767
Name:ROQUE, JOSE JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:
Last Name:ROQUE
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4280 BEE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-2563
Mailing Address - Country:US
Mailing Address - Phone:941-363-6381
Mailing Address - Fax:
Practice Address - Street 1:4280 BEE RIDGE RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-2563
Practice Address - Country:US
Practice Address - Phone:941-363-6381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-07
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61053390200000X
FLDN212671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program