Healthcare Provider Details

I. General information

NPI: 1598327793
Provider Name (Legal Business Name): SAIMEL ROQUE DE ESCOBAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 09/24/2021
Certification Date: 08/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 E FOWLER AVE
TAMPA FL
33612-5511
US

IV. Provider business mailing address

6713 W CLIFTON ST
TAMPA FL
33634-5011
US

V. Phone/Fax

Practice location:
  • Phone: 787-876-2042
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN26485
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: