Provider Demographics
NPI:1275526972
Name:HUDSON, KEVIN EDWARD (DDS, RN)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:EDWARD
Last Name:HUDSON
Suffix:
Gender:M
Credentials:DDS, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 SPEARFISH LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3322
Mailing Address - Country:US
Mailing Address - Phone:619-733-0169
Mailing Address - Fax:
Practice Address - Street 1:USS NIMITZ
Practice Address - Street 2:CVN-68
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96620-2820
Practice Address - Country:US
Practice Address - Phone:619-545-8711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 00009590122300000X
IDD-3737122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist