Provider Demographics
NPI:1891174793
Name:WU, YICHING JEANNIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:YICHING
Middle Name:JEANNIE
Last Name:WU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2628 E JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-2724
Mailing Address - Country:US
Mailing Address - Phone:574-233-7266
Mailing Address - Fax:574-233-7560
Practice Address - Street 1:2628 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-2724
Practice Address - Country:US
Practice Address - Phone:574-233-7266
Practice Address - Fax:574-233-7560
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040338122300000X
IN12012664A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist