Provider Demographics
NPI:1639588833
Name:ADVANCED FAMILY DENTAL & ORTHODONTICS OF MT. OLIVE, P.C.
Entity Type:Organization
Organization Name:ADVANCED FAMILY DENTAL & ORTHODONTICS OF MT. OLIVE, 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:
Authorized Official - Last Name:RUBIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-741-1700
Mailing Address - Street 1:312 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:IL
Mailing Address - Zip Code:62069-1640
Mailing Address - Country:US
Mailing Address - Phone:217-999-6211
Mailing Address - Fax:
Practice Address - Street 1:312 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:IL
Practice Address - Zip Code:62069-1640
Practice Address - Country:US
Practice Address - Phone:217-999-6211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED FAMILY DENTAL & ORTHODONTICS OF CARLINVILLE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-13
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019016447122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty