Provider Demographics
NPI:1245229822
Name:XU, YUDONG (DMD)
Entity Type:Individual
Prefix:
First Name:YUDONG
Middle Name:
Last Name:XU
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 1:1612 MULLIKIN DR
Mailing Address - Street 2:APT 204
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-8307
Mailing Address - Country:US
Mailing Address - Phone:217-364-7235
Mailing Address - Fax:
Practice Address - Street 1:303 W SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4817
Practice Address - Country:US
Practice Address - Phone:217-356-3335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190268101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9178971Medicaid