Provider Demographics
NPI:1023239365
Name:JUDGE, GURSIMRAT K (DDS)
Entity type:Individual
Prefix:DR
First Name:GURSIMRAT
Middle Name:K
Last Name:JUDGE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5104 WATERFORD WOODWAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066
Mailing Address - Country:US
Mailing Address - Phone:315-336-0494
Mailing Address - Fax:
Practice Address - Street 1:GREAT LAKES DENTAL SERVICES, PC
Practice Address - Street 2:107 E CHESTNUT ST.
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440
Practice Address - Country:US
Practice Address - Phone:315-336-0494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045649122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01552501Medicaid