Provider Demographics
NPI:1467645812
Name:ROQUE, EDGAR DONES (DDS)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:DONES
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 1:420 W SHIELDS AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-4107
Mailing Address - Country:US
Mailing Address - Phone:559-412-4702
Mailing Address - Fax:559-473-1475
Practice Address - Street 1:420 W SHIELDS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705-4107
Practice Address - Country:US
Practice Address - Phone:559-412-4702
Practice Address - Fax:559-473-1475
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55681OtherDOCTORS LICENSE