Provider Demographics
NPI:1467482976
Name:TAGUE, JAMES ROBERT (DMD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ROBERT
Last Name:TAGUE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA BAY
Mailing Address - State:NY
Mailing Address - Zip Code:13607
Mailing Address - Country:US
Mailing Address - Phone:315-482-9941
Mailing Address - Fax:315-482-2783
Practice Address - Street 1:138 CHURCH ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA BAY
Practice Address - State:NY
Practice Address - Zip Code:13607
Practice Address - Country:US
Practice Address - Phone:315-482-9941
Practice Address - Fax:315-482-2783
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038171122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02407683Medicaid
NY02407683Medicaid