Provider Demographics
NPI:1770875684
Name:ROQUE RUANO, MAIKEL
Entity type:Individual
Prefix:
First Name:MAIKEL
Middle Name:
Last Name:ROQUE RUANO
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 1:6085 BIRD RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-5254
Mailing Address - Country:US
Mailing Address - Phone:305-665-3433
Mailing Address - Fax:
Practice Address - Street 1:6085 BIRD RD #200
Practice Address - Street 2:ENDODONTIC SPECIALISTS
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155
Practice Address - Country:US
Practice Address - Phone:305-665-3433
Practice Address - Fax:305-667-3775
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2021-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI2901021373122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program