Provider Demographics
NPI:1447214424
Name:HUDSON, GARY W (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:W
Last Name:HUDSON
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 EAGLETREE LN SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6447
Mailing Address - Country:US
Mailing Address - Phone:256-882-7873
Mailing Address - Fax:256-882-7874
Practice Address - Street 1:1105 EAGLETREE LN SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6447
Practice Address - Country:US
Practice Address - Phone:256-882-7873
Practice Address - Fax:256-882-7874
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12133204E00000X
AL36771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL760775732OtherPRINCIPAL
AL760775732OtherMETLIFE
AL008606360Medicaid
AL760775732OtherAMERITAS
AL760775732OtherGUARDIAN
AL760775732OtherCIGNA
AL760775732OtherSOUTHLAND
AL760775732OtherMAIL HANDLERS
AL760775732OtherAETNA
AL720892OtherUNITED CONCORDIA
AL760775732OtherNAMCI
AL51000927OtherBLUE CROSS BLUE SHIELD AL
AL760775732OtherDELTA DENTAL
AL760775732OtherWASHINGTON DENTAL
AL760775732OtherJARDINES
AL760775732OtherNAMCI
AL760775732OtherPRINCIPAL