Provider Demographics
NPI:1346261450
Name:FAUBLE DENTAL HEALTHCARE ASSOCIATES, PC
Entity Type:Organization
Organization Name:FAUBLE DENTAL HEALTHCARE ASSOCIATES, PC
Other - Org Name:ADVANCED DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:V
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-228-1085
Mailing Address - Street 1:4561 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-5851
Mailing Address - Country:US
Mailing Address - Phone:217-228-1085
Mailing Address - Fax:217-228-1089
Practice Address - Street 1:4561 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-5851
Practice Address - Country:US
Practice Address - Phone:217-228-1085
Practice Address - Fax:217-228-1089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0213411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1004529Medicaid