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General NPI Number Information
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NPI Number | 1780363432
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Entity Type | Individual
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Provider Name | MARIA ROQUE
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Gender | Female
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Dates
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Enumeration Date | 07/11/2023
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Last Update Date | 04/28/2025
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Provider Practice Location Address
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Address Line | 220 E COMMERCE CT STE A
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City | ELKHORN
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State | WI
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Zip | 53121-4371
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Country | US
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Telephone | 262-723-3224
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Fax |
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Provider Business Mailing Address
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Address Line | 1105 S 32ND ST
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City | MILWAUKEE
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State | WI
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Zip | 53215-1553
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Country | US
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Telephone | 143-646-5304
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Fax |
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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 | 6001426-15
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License Number State | WI
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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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