Provider Demographics
NPI:1053459735
Name:HUDSON, MARK RAYMOND (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RAYMOND
Last Name:HUDSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-1842
Mailing Address - Country:US
Mailing Address - Phone:121-776-2945
Mailing Address - Fax:121-776-2945
Practice Address - Street 1:1006 S MARKET ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-1842
Practice Address - Country:US
Practice Address - Phone:121-776-2945
Practice Address - Fax:121-776-2945
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice