Provider Demographics
NPI:1831581537
Name:EDGAR D. ROQUE, D.D.S., INC
Entity type:Organization
Organization Name:EDGAR D. ROQUE, D.D.S., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:DONES
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-772-8852
Mailing Address - Street 1:719 N DOUTY ST
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-3986
Mailing Address - Country:US
Mailing Address - Phone:559-772-8852
Mailing Address - Fax:559-473-1475
Practice Address - Street 1:719 N DOUTY ST
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-3986
Practice Address - Country:US
Practice Address - Phone:559-772-8852
Practice Address - Fax:559-473-1475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-04
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty