Healthcare Provider Details

I. General information

NPI: 1780657221
Provider Name (Legal Business Name): WILLIAM HART ANDERSON III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 6TH ST NAVAL HOSPITAL, DENTAL DIRECTORATE
GREAT LAKES IL
60088-2833
US

IV. Provider business mailing address

135 W NEWBRIDGE LN
ROUND LAKE IL
60073-5645
US

V. Phone/Fax

Practice location:
  • Phone: 184-768-8242
  • Fax: 184-768-8440
Mailing address:
  • Phone: 184-768-8242
  • Fax: 184-768-8440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number20084
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: