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General NPI Number Information
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NPI Number | 1467347732
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Entity Type | Organization
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Legal Business Name | SOUTHERN ILLINOIS FAMILY DENTISTRY LLC
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Dates
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Enumeration Date | 06/09/2025
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Last Update Date | 06/09/2025
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Provider Practice Location Address
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Address Line | 1030 4TH ST
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City | ELDORADO
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State | IL
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Zip | 62930-1702
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Country | US
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Telephone | 618-273-9361
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Fax |
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Provider Business Mailing Address
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Address Line | 7754 STATE ROUTE 14
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City | MC LEANSBORO
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State | IL
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Zip | 62859-4501
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Country | US
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Telephone | 618-841-6431
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | EMILY RUBENACKER
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Credential |
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Telephone | 618-841-6431
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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