Provider Demographics
NPI:1558467530
Name:NINO DE GUZMAN ROACH, PATRICIA (DDS)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:NINO DE GUZMAN ROACH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 W LAKE MARY BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3571
Mailing Address - Country:US
Mailing Address - Phone:407-688-9990
Mailing Address - Fax:407-688-9991
Practice Address - Street 1:3300 W LAKE MARY BLVD STE 250
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3571
Practice Address - Country:US
Practice Address - Phone:407-688-9990
Practice Address - Fax:407-688-9991
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053618122300000X
390200000X
FLDN19963122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program