Healthcare Provider Details

I. General information

NPI: 1023419124
Provider Name (Legal Business Name): DAVID ROQUIZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11132 MORNINGSTAR PL
LOMA LINDA CA
92354-6560
US

IV. Provider business mailing address

11132 MORNINGSTAR PL
LOMA LINDA CA
92354-6560
US

V. Phone/Fax

Practice location:
  • Phone: 863-414-0752
  • Fax:
Mailing address:
  • Phone: 863-414-0752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number63993
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: