Provider Demographics
NPI:1699336412
Name:HUDSON, TIFFANY (DDS, MS)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:HUDSON
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30212 VIA VICTORIA
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-4440
Mailing Address - Country:US
Mailing Address - Phone:310-938-6526
Mailing Address - Fax:
Practice Address - Street 1:5363 BALBOA BLVD STE 330
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2831
Practice Address - Country:US
Practice Address - Phone:818-981-0640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1009231223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty