Provider Demographics
NPI:1750477857
Name:TARA HUDSON DDS PC
Entity Type:Organization
Organization Name:TARA HUDSON DDS PC
Other - Org Name:HUDSON FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-659-5611
Mailing Address - Street 1:1622 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4302
Mailing Address - Country:US
Mailing Address - Phone:360-659-5611
Mailing Address - Fax:360-653-9577
Practice Address - Street 1:1622 GROVE ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4302
Practice Address - Country:US
Practice Address - Phone:360-659-5611
Practice Address - Fax:360-653-9577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA85441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5041264Medicaid