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General NPI Number Information
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NPI Number | 1306031281
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Entity Type | Organization
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Legal Business Name | RIVERSIDE DENTAL
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Dates
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Enumeration Date | 09/13/2007
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Last Update Date | 09/13/2007
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Provider Practice Location Address
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Address Line | 9402 N US HIGHWAY 1
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City | SEBASTIAN
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State | FL
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Zip | 32958-6398
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Country | US
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Telephone | 772-589-1140
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Fax |
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Provider Business Mailing Address
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Address Line | 9402 N US HIGHWAY 1
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City | SEBASTIAN
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State | FL
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Zip | 32958-6398
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Country | US
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Telephone | 772-589-1140
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. LOUIS R ROQUE
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Credential | D.D.S.
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Telephone | 772-589-1140
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DN 12242
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License Number State | FL
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