Provider Demographics
NPI:1760533459
Name:WRUCK, LARRY DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DAVID
Last Name:WRUCK
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 1:15855 W NATIONAL AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-5159
Mailing Address - Country:US
Mailing Address - Phone:262-782-4220
Mailing Address - Fax:262-782-5471
Practice Address - Street 1:15855 W NATIONAL AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-5159
Practice Address - Country:US
Practice Address - Phone:262-782-4220
Practice Address - Fax:262-782-5471
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1632G1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice