Provider Demographics
NPI:1568841344
Name:ILLINI SMILES DENTAL CARE PC
Entity Type:Organization
Organization Name:ILLINI SMILES DENTAL CARE PC
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:DMD
Authorized Official - Phone:217-607-1292
Mailing Address - Street 1:125 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 W MAIN ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2714
Practice Address - Country:US
Practice Address - Phone:217-607-1292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190268101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty