Provider Demographics
NPI:1689365025
Name:ROQUE GONZALEZ, AMAURY
Entity type:Individual
Prefix:
First Name:AMAURY
Middle Name:
Last Name:ROQUE GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. CAPARRA TERRACE 1590 ST. 2 SW
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921
Mailing Address - Country:US
Mailing Address - Phone:787-325-7426
Mailing Address - Fax:
Practice Address - Street 1:BO. MONTONES CARR 183 RAMAL 9939, PARQ. INDUSTRIAL
Practice Address - Street 2:LOTE 19
Practice Address - City:LAS PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00771
Practice Address - Country:US
Practice Address - Phone:939-286-1612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR35111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice