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General NPI Number Information
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NPI Number | 1083802524
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Entity Type | Organization
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Legal Business Name | AVID DENTAL PC
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Dates
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Enumeration Date | 10/10/2007
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Last Update Date | 10/10/2007
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Provider Practice Location Address
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Address Line | 115 REPUBLIC AVE
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City | JOLIET
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State | IL
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Zip | 60435-6515
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Country | US
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Telephone | 815-483-2040
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Fax | 815-483-2071
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Provider Business Mailing Address
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Address Line | 115 REPUBLIC AVE
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City | JOLIET
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State | IL
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Zip | 60435-6515
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Country | US
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Telephone | 815-483-2040
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Fax | 815-483-2071
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. DAVID JOSEPH RUBIS
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Credential | DDS
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Telephone | 815-483-2040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 19016647
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License Number State | IL
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