Provider Demographics
NPI:1275982936
Name:ROQUE, MIGUEL A (DMD, MMSC)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:A
Last Name:ROQUE
Suffix:
Gender:M
Credentials:DMD, MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1087 BEACON ST STE 104
Mailing Address - Street 2:
Mailing Address - City:NEWTON CENTRE
Mailing Address - State:MA
Mailing Address - Zip Code:02459-1700
Mailing Address - Country:US
Mailing Address - Phone:617-410-8595
Mailing Address - Fax:978-977-3458
Practice Address - Street 1:1087 BEACON ST STE 104
Practice Address - Street 2:
Practice Address - City:NEWTON CENTRE
Practice Address - State:MA
Practice Address - Zip Code:02459-1700
Practice Address - Country:US
Practice Address - Phone:617-410-8595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18572481223G0001X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice