Healthcare Provider Details

I. General information

NPI: 1568841344
Provider Name (Legal Business Name): ILLINI SMILES DENTAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 FOX DR STE B
CHAMPAIGN IL
61820-7596
US

IV. Provider business mailing address

2110 FOX DR STE B
CHAMPAIGN IL
61820-7596
US

V. Phone/Fax

Practice location:
  • Phone: 217-269-0450
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019026810
License Number StateIL

VIII. Authorized Official

Name: YUDONG XU
Title or Position: PRESIDENT
Credential: DMD
Phone: 217-356-3335