Provider Demographics
NPI:1174623359
Name:MRUK, JAMES G (DDS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:G
Last Name:MRUK
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 1:11 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NY
Mailing Address - Zip Code:14772-1103
Mailing Address - Country:US
Mailing Address - Phone:716-358-6001
Mailing Address - Fax:716-358-6011
Practice Address - Street 1:11 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NY
Practice Address - Zip Code:14772-1103
Practice Address - Country:US
Practice Address - Phone:716-358-6001
Practice Address - Fax:716-358-6011
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY26075122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00981902Medicaid
NY000770077001OtherCHILD HEALTH CARE PLUS
NY584157OtherUNITED CONCORDIA INS