Healthcare Provider Details

I. General information

NPI: 1629360664
Provider Name (Legal Business Name): ADVANCED FAMILY DENTAL & ORTHODONTICS P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 10/17/2012
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
60403-1881
US

V. Phone/Fax

Practice location:
  • Phone: 815-741-1700
  • Fax: 815-483-2298
Mailing address:
  • Phone: 815-741-1700
  • Fax: 815-483-2298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019016447
License Number StateIL

VIII. Authorized Official

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