Basic Information
| Provider Information | |||||||||
| NPI: | 1043676604 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | E H DUDLEY, DDS, PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ASPEN DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3189 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132203189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154546000 | ||||||||
| FaxNumber: | 3154105531 | ||||||||
| Practice Location | |||||||||
| Address1: | 1119 VANN DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383056098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316608981 | ||||||||
| FaxNumber: | 7316607398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2016 | ||||||||
| LastUpdateDate: | 01/12/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUDLEY | ||||||||
| AuthorizedOfficialFirstName: | ELLIOTT | ||||||||
| AuthorizedOfficialMiddleName: | HODGES | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7316608981 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DS0000009633 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.