Provider Demographics
NPI:1154508034
Name:AVID DENTAL
Entity Type:Organization
Organization Name:AVID DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUBIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-483-2040
Mailing Address - Street 1:115 REPUBLIC AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6515
Mailing Address - Country:US
Mailing Address - Phone:815-483-2040
Mailing Address - Fax:815-741-8511
Practice Address - Street 1:115 REPUBLIC AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6515
Practice Address - Country:US
Practice Address - Phone:815-483-2040
Practice Address - Fax:815-741-8511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty