Provider Demographics
NPI:1649359126
Name:HUDSON, BRADLEY D (DMD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:D
Last Name:HUDSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 S DURKIN DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6018
Mailing Address - Country:US
Mailing Address - Phone:217-793-1979
Mailing Address - Fax:217-793-3449
Practice Address - Street 1:927 S DURKIN DR
Practice Address - Street 2:SUITE B
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6018
Practice Address - Country:US
Practice Address - Phone:217-793-1979
Practice Address - Fax:217-793-3449
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice