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General NPI Number Information
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NPI Number | 1558467530
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Entity Type | Individual
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Provider Name | PATRICIA NINO DE GUZMAN ROACH DDS
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Gender | Female
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Dates
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Enumeration Date | 09/16/2006
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Last Update Date | 03/06/2015
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Provider Practice Location Address
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Address Line | 3300 W LAKE MARY BLVD STE 250
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City | LAKE MARY
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State | FL
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Zip | 32746-3571
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Country | US
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Telephone | 407-688-9990
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Fax | 407-688-9991
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Provider Business Mailing Address
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Address Line | 3300 W LAKE MARY BLVD STE 250
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City | LAKE MARY
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State | FL
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Zip | 32746-3571
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Country | US
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Telephone | 407-688-9990
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Fax | 407-688-9991
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 053618
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN19963
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License Number State | FL
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