Provider Demographics
NPI:1932648201
Name:XU, DAVID JIAYUAN (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JIAYUAN
Last Name:XU
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 1:2066 E 26TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-2442
Mailing Address - Country:US
Mailing Address - Phone:917-724-4172
Mailing Address - Fax:
Practice Address - Street 1:2521 VESTAL PKWY W
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850
Practice Address - Country:US
Practice Address - Phone:607-754-2217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-18
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059877-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice