Provider Demographics
NPI:1962765875
Name:HUDSON, JOSHUA A (DMD)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:A
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 1:2404 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1859
Mailing Address - Country:US
Mailing Address - Phone:309-699-5521
Mailing Address - Fax:309-699-7050
Practice Address - Street 1:2404 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-1859
Practice Address - Country:US
Practice Address - Phone:309-699-5521
Practice Address - Fax:309-699-7050
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190290201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice