Healthcare Provider Details

I. General information

NPI: 1306225727
Provider Name (Legal Business Name): DOUGLAS HUDOBA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 OH-3
SUNBURY OH
43074
US

IV. Provider business mailing address

3111 COLUMBUS ST
GROVE CITY OH
43123-2762
US

V. Phone/Fax

Practice location:
  • Phone: 614-450-0025
  • Fax:
Mailing address:
  • Phone: 614-871-0088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.024450
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: