Healthcare Provider Details

I. General information

NPI: 1275734865
Provider Name (Legal Business Name): ADVANCED FAMILY DENTAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2241 THEODORE ST.
CREST HILL IL
60403-1881
US

IV. Provider business mailing address

2241 THEODORE ST
CREST HILL IL
60435-1881
US

V. Phone/Fax

Practice location:
  • Phone: 815-741-1700
  • Fax: 815-741-8511
Mailing address:
  • Phone: 815-741-1700
  • Fax: 815-741-8511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number19016447
License Number StateIL

VIII. Authorized Official

Name: DR. DAVID J. RUBIS
Title or Position: OWNER
Credential: DDS
Phone: 815-741-1700