Provider Demographics
NPI:1851420475
Name:YU, JIM W (DDS)
Entity Type:Individual
Prefix:DR
First Name:JIM
Middle Name:W
Last Name:YU
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 1:1905 CONVENIENCE PL
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-8926
Mailing Address - Country:US
Mailing Address - Phone:217-355-5165
Mailing Address - Fax:217-355-5189
Practice Address - Street 1:1905 CONVENIENCE PL
Practice Address - Street 2:SUITE A
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-8926
Practice Address - Country:US
Practice Address - Phone:217-355-5165
Practice Address - Fax:217-355-5189
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1004780Medicaid