Provider Demographics
NPI:1750640439
Name:KEITH RUTER LLC DBA RIVERSIDE DENTAL
Entity Type:Organization
Organization Name:KEITH RUTER LLC DBA RIVERSIDE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:R
Authorized Official - Last Name:RUTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-938-2566
Mailing Address - Street 1:401 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNA
Mailing Address - State:IL
Mailing Address - Zip Code:61074-1535
Mailing Address - Country:US
Mailing Address - Phone:815-273-2212
Mailing Address - Fax:815-273-1081
Practice Address - Street 1:401 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAVANNA
Practice Address - State:IL
Practice Address - Zip Code:61074-1535
Practice Address - Country:US
Practice Address - Phone:815-273-2212
Practice Address - Fax:815-273-1081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190195701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty