Healthcare Provider Details

I. General information

NPI: 1447214424
Provider Name (Legal Business Name): GARY W HUDSON D.M.D., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 10/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 EAGLETREE LN SE
HUNTSVILLE AL
35801-6447
US

IV. Provider business mailing address

1105 EAGLETREE LN SE
HUNTSVILLE AL
35801-6447
US

V. Phone/Fax

Practice location:
  • Phone: 256-882-7873
  • Fax: 256-882-7874
Mailing address:
  • Phone: 256-882-7873
  • Fax: 256-882-7874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number12133
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3677
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: