Provider Demographics
NPI:1467347732
Name:SOUTHERN ILLINOIS FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBENACKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-841-6431
Mailing Address - Street 1:7754 STATE ROUTE 14
Mailing Address - Street 2:
Mailing Address - City:MC LEANSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62859-4501
Mailing Address - Country:US
Mailing Address - Phone:618-841-6431
Mailing Address - Fax:
Practice Address - Street 1:1030 4TH ST
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-1702
Practice Address - Country:US
Practice Address - Phone:618-273-9361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty