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General NPI Number Information
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NPI Number | 1851583603
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Entity Type | Organization
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Legal Business Name | ORAL AND MAXILLO FACIAL SURGEONS FOR NORTHERN ILLINOIS
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Dates
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Enumeration Date | 08/15/2007
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Last Update Date | 07/19/2019
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Provider Practice Location Address
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Address Line | 1675 BETHANY RD SUITE A
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City | SYCAMORE
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State | IL
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Zip | 60178
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Country | US
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Telephone | 815-895-3000
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Fax | 815-895-0505
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Provider Business Mailing Address
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Address Line | 1675 BETHANY RD SUITE A
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City | SYCAMORE
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State | IL
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Zip | 60178
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Country | US
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Telephone | 815-895-3000
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Fax | 815-895-0505
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Authorized Official
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Title or Position | PRESIDENT
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Name | TODD M ANDERSON
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Credential | DDS
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Telephone | 815-595-3000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number |
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License Number State |
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