Healthcare Provider Details

I. General information

NPI: 1780363432
Provider Name (Legal Business Name): MARIA ROQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 E COMMERCE CT STE A
ELKHORN WI
53121-4371
US

IV. Provider business mailing address

1105 S 32ND ST
MILWAUKEE WI
53215-1553
US

V. Phone/Fax

Practice location:
  • Phone: 262-723-3224
  • Fax:
Mailing address:
  • Phone: 143-646-5304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6001426-15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: