Provider Demographics
NPI:1255738787
Name:JIM YU, D.D.S. PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:JIM YU, D.D.S. PROFESSIONAL DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5699
Mailing Address - Street 1:2231 W GRANT LINE RD STE 134
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-7325
Mailing Address - Country:US
Mailing Address - Phone:209-227-2579
Mailing Address - Fax:
Practice Address - Street 1:2231 W GRANT LINE RD STE 134
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-7325
Practice Address - Country:US
Practice Address - Phone:209-227-2579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JIM YU, D.D.S. PROFESSIONAL DENTAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty