Provider Demographics
NPI:1992848097
Name:ARCHIBALD, JUDITH CHARLENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:CHARLENE
Last Name:ARCHIBALD
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 1:1220 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-1986
Mailing Address - Country:US
Mailing Address - Phone:906-482-4262
Mailing Address - Fax:906-482-4356
Practice Address - Street 1:1220 MILITARY RD
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-1986
Practice Address - Country:US
Practice Address - Phone:906-482-4262
Practice Address - Fax:906-482-4356
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0127231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4061461Medicaid