Provider Demographics
NPI:1871689950
Name:HUDSON, TARA L (DDS)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
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 1:1622 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
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA8544122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5041280Medicaid