Provider Demographics
NPI:1942392642
Name:ROECKER, DAVID A (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:ROECKER
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:PO BOX 962
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-0962
Mailing Address - Country:US
Mailing Address - Phone:909-875-1363
Mailing Address - Fax:909-875-1052
Practice Address - Street 1:224 N RIVERSIDE AVE
Practice Address - Street 2:STE. B
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5968
Practice Address - Country:US
Practice Address - Phone:909-875-1363
Practice Address - Fax:909-875-1052
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA389071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice