Provider Demographics
NPI:1104346220
Name:ILLINI SMILES DENTAL CARE P.C.
Entity type:Organization
Organization Name:ILLINI SMILES DENTAL CARE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YUDONG
Authorized Official - Middle Name:
Authorized Official - Last Name:XU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-892-8868
Mailing Address - Street 1:730 ENTERPRISE
Mailing Address - Street 2:
Mailing Address - City:RANTOUL
Mailing Address - State:IL
Mailing Address - Zip Code:61866-3689
Mailing Address - Country:US
Mailing Address - Phone:217-892-8868
Mailing Address - Fax:
Practice Address - Street 1:225 N MARKET ST
Practice Address - Street 2:
Practice Address - City:PAXTON
Practice Address - State:IL
Practice Address - Zip Code:60957-1189
Practice Address - Country:US
Practice Address - Phone:217-379-4614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty