Provider Demographics
NPI:1467060111
Name:YUAN, ILI (DMD)
Entity type:Individual
Prefix:
First Name:ILI
Middle Name:
Last Name:YUAN
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 1:1601 HWY 40 E
Mailing Address - Street 2:STE M PMB 242
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548
Mailing Address - Country:US
Mailing Address - Phone:502-365-8388
Mailing Address - Fax:
Practice Address - Street 1:881 USS JAMES MADISON RD BLDG 1028
Practice Address - Street 2:
Practice Address - City:KINGS BAY
Practice Address - State:GA
Practice Address - Zip Code:31547-2531
Practice Address - Country:US
Practice Address - Phone:912-573-4215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11287122300000X
KYTEMP122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist