Healthcare Provider Details

I. General information

NPI: 1093111767
Provider Name (Legal Business Name): JOSE ROQUE JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2014
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4280 BEE RIDGE RD
SARASOTA FL
34233-2563
US

IV. Provider business mailing address

4280 BEE RIDGE RD
SARASOTA FL
34233-2563
US

V. Phone/Fax

Practice location:
  • Phone: 941-363-6381
  • Fax:
Mailing address:
  • Phone: 941-363-6381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number61053
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN21267
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: