Provider Demographics
NPI:1457703696
Name:MONIQUE HUDSON,DDS, PA
Entity Type:Organization
Organization Name:MONIQUE HUDSON,DDS, PA
Other - Org Name:MONROE DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-289-1105
Mailing Address - Street 1:2200 WALTERS DIVISION RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-8562
Mailing Address - Country:US
Mailing Address - Phone:704-289-1105
Mailing Address - Fax:704-289-6269
Practice Address - Street 1:2200 WALTERS DIVISION RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-8562
Practice Address - Country:US
Practice Address - Phone:704-289-1105
Practice Address - Fax:704-289-6269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7370122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899019KMedicaid