Healthcare Provider Details

I. General information

NPI: 1174623359
Provider Name (Legal Business Name): JAMES G MRUK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SCHOOL ST
RANDOLPH NY
14772-1103
US

IV. Provider business mailing address

11 SCHOOL ST
RANDOLPH NY
14772-1103
US

V. Phone/Fax

Practice location:
  • Phone: 716-358-6001
  • Fax: 716-358-6011
Mailing address:
  • Phone: 716-358-6001
  • Fax: 716-358-6011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number26075
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: