Healthcare Provider Details

I. General information

NPI: 1275294670
Provider Name (Legal Business Name): DAVID HARRISON HUDSON DMD MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 01/07/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

997 CLOCK TOWER DR
SPRINGFIELD IL
62704-1301
US

IV. Provider business mailing address

997 CLOCK TOWER DR
SPRINGFIELD IL
62704-1301
US

V. Phone/Fax

Practice location:
  • Phone: 217-546-9600
  • Fax:
Mailing address:
  • Phone: 217-546-9600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021.003156
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: