Provider Demographics
NPI:1902968522
Name:HUDELSON, LEE DAVID (DDS)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:DAVID
Last Name:HUDELSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 3RD AVE E
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-1731
Mailing Address - Country:US
Mailing Address - Phone:218-262-5536
Mailing Address - Fax:218-263-8554
Practice Address - Street 1:2011 3RD AVE E
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-1731
Practice Address - Country:US
Practice Address - Phone:218-262-5536
Practice Address - Fax:218-263-8554
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND107111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice