Provider Demographics
NPI:1770359515
Name:AFFINITY DENTAL CHAMPAIGN LLC
Entity type:Organization
Organization Name:AFFINITY DENTAL CHAMPAIGN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DURSHANAPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:217-298-7999
Mailing Address - Street 1:2918 CROSSING CT STE A
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-6100
Mailing Address - Country:US
Mailing Address - Phone:217-298-7999
Mailing Address - Fax:217-888-3899
Practice Address - Street 1:2918 CROSSING CT STE A
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-6100
Practice Address - Country:US
Practice Address - Phone:217-298-7999
Practice Address - Fax:217-888-3899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty