Provider Demographics
NPI:1770688202
Name:ROARK, DOMINICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOMINICK
Middle Name:
Last Name:ROARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:DOMINICK
Other - Middle Name:
Other - Last Name:ROARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:E43 EL ALAMO DR
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969-4542
Mailing Address - Country:US
Mailing Address - Phone:787-288-5994
Mailing Address - Fax:787-288-5994
Practice Address - Street 1:E43 EL ALAMO DR
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969-4542
Practice Address - Country:US
Practice Address - Phone:787-288-5994
Practice Address - Fax:787-288-5994
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR23791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR582798220Medicare ID - Type Unspecified1026