Provider Demographics
NPI:1417208455
Name:ILLINI SMILES DENTAL CARE P.C.
Entity Type:Organization
Organization Name:ILLINI SMILES DENTAL CARE P.C.
Other - Org Name:ANGEL SMILES DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YUDONG
Authorized Official - Middle Name:
Authorized Official - Last Name:XU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-364-7235
Mailing Address - Street 1:2803 CHERRY HILLS DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-7541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:730 ENTERPRISE
Practice Address - Street 2:
Practice Address - City:RANTOUL
Practice Address - State:IL
Practice Address - Zip Code:61866-3689
Practice Address - Country:US
Practice Address - Phone:217-364-7235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190268101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty