Provider Demographics
NPI:1114076817
Name:ROQUE, PAUL G (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:G
Last Name:ROQUE
Suffix:
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 1:642 NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02861-3238
Mailing Address - Country:US
Mailing Address - Phone:401-722-3757
Mailing Address - Fax:401-722-3757
Practice Address - Street 1:642 NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02861-3238
Practice Address - Country:US
Practice Address - Phone:401-722-3757
Practice Address - Fax:401-722-3757
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI 21261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPR00814Medicaid