Provider Demographics
NPI:1194175240
Name:HUDOBA DENTAL 1, INC
Entity type:Organization
Organization Name:HUDOBA DENTAL 1, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDOBA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-450-0025
Mailing Address - Street 1:4883 ELKS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-1709
Mailing Address - Country:US
Mailing Address - Phone:614-450-0025
Mailing Address - Fax:
Practice Address - Street 1:169 OH-3
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:OH
Practice Address - Zip Code:43074
Practice Address - Country:US
Practice Address - Phone:614-450-0025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.024450122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty