MEDICARE: KEITH RUTER LLC DBA RIVERSIDE DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019019570	IL

General Provider Information

NPI Number	:	1750640439
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEITH RUTER LLC DBA RIVERSIDE DENTAL

Provider Business Mailing Address
First Line	:	401 MAIN ST
Second Line	:
City	:	SAVANNA
State	:	IL
Zip	:	61074-1535
Country	:	US
Telephone Number	:	815-273-2212
Fax Number	:	815-273-1081

Provider Business Practice Location Address
First Line	:	401 MAIN ST
Second Line	:
City	:	SAVANNA
State	:	IL
Zip	:	61074-1535
Country	:	US
Telephone Number	:	815-273-2212
Fax Number	:	815-273-1081

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KEITH R RUTER
Credential	:	DDS
Telephone Number	:	815-938-2566

Provider Enumeration Date	:	05/15/2012
Last Update Date	:	10/29/2013

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