Healthcare Provider Details

I. General information

NPI: 1770359515
Provider Name (Legal Business Name): AFFINITY DENTAL CHAMPAIGN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2918 CROSSING CT STE A
CHAMPAIGN IL
61822-6100
US

IV. Provider business mailing address

2918 CROSSING CT STE A
CHAMPAIGN IL
61822-6100
US

V. Phone/Fax

Practice location:
  • Phone: 217-298-7999
  • Fax: 217-888-3899
Mailing address:
  • Phone: 217-298-7999
  • Fax: 217-888-3899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SRINIVAS DURSHANAPALLI
Title or Position: PRESIDENT
Credential: DDS
Phone: 217-298-7999