Provider Demographics
NPI:1083263933
Name:HUDSON, KEANDRA (RDH)
Entity Type:Individual
Prefix:
First Name:KEANDRA
Middle Name:
Last Name:HUDSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21110 EDEN DR APT 319
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20166-6665
Mailing Address - Country:US
Mailing Address - Phone:903-949-1877
Mailing Address - Fax:
Practice Address - Street 1:4 ATLANTIC ST SW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-2350
Practice Address - Country:US
Practice Address - Phone:202-540-9862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHYG10000960124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist