Healthcare Provider Details

I. General information

NPI: 1568562809
Provider Name (Legal Business Name): GARRY D HUDSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7146 SR 247
POTTSVILLE AR
72858-8891
US

IV. Provider business mailing address

7146 SR 247
POTTSVILLE AR
72858-8891
US

V. Phone/Fax

Practice location:
  • Phone: 479-858-7382
  • Fax: 479-858-7323
Mailing address:
  • Phone: 479-858-7382
  • Fax: 479-858-7323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberAR2123
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: