Provider Demographics
NPI:1205828423
Name:ROA, JOSE ARISTIDES (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:ARISTIDES
Last Name:ROA
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 1:4071 DENMAN ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1608
Mailing Address - Country:US
Mailing Address - Phone:718-476-1573
Mailing Address - Fax:718-478-2485
Practice Address - Street 1:4071 DENMAN ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1608
Practice Address - Country:US
Practice Address - Phone:718-476-1573
Practice Address - Fax:718-478-2485
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0448191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01460186Medicaid