Provider Demographics
NPI:1912174004
Name:MARISCAL, ROQUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROQUE
Middle Name:
Last Name:MARISCAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 N SAN SABA
Mailing Address - Street 2:SUITE 925
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3154
Mailing Address - Country:US
Mailing Address - Phone:210-227-1991
Mailing Address - Fax:
Practice Address - Street 1:315 N SAN SABA
Practice Address - Street 2:SUITE 925
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3154
Practice Address - Country:US
Practice Address - Phone:210-227-1991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX153481223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1209736-02Medicaid