Healthcare Provider Details

I. General information

NPI: 1639588833
Provider Name (Legal Business Name): ADVANCED FAMILY DENTAL & ORTHODONTICS OF MT. OLIVE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 03/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 W MAIN ST
MOUNT OLIVE IL
62069-1640
US

IV. Provider business mailing address

312 W MAIN ST
MOUNT OLIVE IL
62069-1640
US

V. Phone/Fax

Practice location:
  • Phone: 217-999-6211
  • Fax:
Mailing address:
  • Phone: 217-999-6211
  • Fax:

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 RUBIS
Title or Position: PRESIDENT
Credential: DDS
Phone: 815-741-1700