Provider Demographics
NPI:1386724136
Name:SCRUGGS, CARL RICHARD JR (DDS)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:RICHARD
Last Name:SCRUGGS
Suffix:JR
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 1:37 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-1162
Mailing Address - Country:US
Mailing Address - Phone:315-769-5811
Mailing Address - Fax:315-769-9236
Practice Address - Street 1:37 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662-1162
Practice Address - Country:US
Practice Address - Phone:315-769-5811
Practice Address - Fax:315-769-9236
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0356201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00706143Medicaid