=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831581537
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDGAR D. ROQUE, D.D.S., INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2015
-----------------------------------------------------
Last Update Date | 03/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 719 N DOUTY ST
-----------------------------------------------------
City | HANFORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93230-3986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-772-8852
-----------------------------------------------------
Fax | 559-473-1475
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 719 N DOUTY ST
-----------------------------------------------------
City | HANFORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93230-3986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-772-8852
-----------------------------------------------------
Fax | 559-473-1475
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. EDGAR DONES ROQUE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 559-772-8852
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 55681
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------