Provider Demographics
NPI:1538124482
Name:HUDSON, MICHELLE J (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:J
Last Name:HUDSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2908
Mailing Address - Country:US
Mailing Address - Phone:215-599-4851
Mailing Address - Fax:215-232-4093
Practice Address - Street 1:401-55 W ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-3644
Practice Address - Country:US
Practice Address - Phone:215-291-2500
Practice Address - Fax:215-291-2580
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS027577L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001622981Medicaid
PA001622981Medicaid
PA099465F61Medicare ID - Type Unspecified