Provider Demographics
NPI:1063685501
Name:ROY A HUDSON III DDS VANCE AVENUE DENTAL CLINIC
Entity Type:Organization
Organization Name:ROY A HUDSON III DDS VANCE AVENUE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:ADRAIN
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-526-4442
Mailing Address - Street 1:516 VANCE AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38126-2117
Mailing Address - Country:US
Mailing Address - Phone:901-526-4442
Mailing Address - Fax:901-526-8523
Practice Address - Street 1:516 VANCE AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38126-2117
Practice Address - Country:US
Practice Address - Phone:901-526-4442
Practice Address - Fax:901-526-8523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000070591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3202421Medicaid