Provider Demographics
NPI:1629360664
Name:ADVANCED FAMILY DENTAL & ORTHODONTICS P C
Entity Type:Organization
Organization Name:ADVANCED FAMILY DENTAL & ORTHODONTICS P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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:815-741-1700
Mailing Address - Street 1:2241 THEODORE ST
Mailing Address - Street 2:
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60403-1881
Mailing Address - Country:US
Mailing Address - Phone:815-741-1700
Mailing Address - Fax:815-483-2298
Practice Address - Street 1:2241 THEODORE ST
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-1881
Practice Address - Country:US
Practice Address - Phone:815-741-1700
Practice Address - Fax:815-483-2298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-10
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019016447122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6631280001Medicare NSC