Provider Demographics
NPI:1194173682
Name:WOODSON, XAVIER (DDS)
Entity type:Individual
Prefix:DR
First Name:XAVIER
Middle Name:
Last Name:WOODSON
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 1:3710 N PINE GROVE AVE
Mailing Address - Street 2:313
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-4186
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6560 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60707-3439
Practice Address - Country:US
Practice Address - Phone:773-385-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030841122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist