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General NPI Number Information
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NPI Number | 1770359515
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Entity Type | Organization
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Legal Business Name | AFFINITY DENTAL CHAMPAIGN LLC
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Dates
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Enumeration Date | 12/04/2023
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Last Update Date | 01/23/2024
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Provider Practice Location Address
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Address Line | 2918 CROSSING CT STE A
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City | CHAMPAIGN
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State | IL
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Zip | 61822-6100
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Country | US
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Telephone | 217-298-7999
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Fax | 217-888-3899
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Provider Business Mailing Address
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Address Line | 2918 CROSSING CT STE A
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City | CHAMPAIGN
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State | IL
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Zip | 61822-6100
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Country | US
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Telephone | 217-298-7999
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Fax | 217-888-3899
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Authorized Official
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Title or Position | PRESIDENT
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Name | SRINIVAS DURSHANAPALLI
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Credential | DDS
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Telephone | 217-298-7999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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