Provider Demographics
NPI:1750654281
Name:DR.JACK RUBY CHARTERED
Entity Type:Organization
Organization Name:DR.JACK RUBY CHARTERED
Other - Org Name:OAK LAWN DENTAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:W
Authorized Official - Last Name:RUBY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-598-0717
Mailing Address - Street 1:6735 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2112
Mailing Address - Country:US
Mailing Address - Phone:708-598-0717
Mailing Address - Fax:
Practice Address - Street 1:6735 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2112
Practice Address - Country:US
Practice Address - Phone:708-598-0717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty