MEDICARE: DR. ALEXANDRA ANDERSON D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019025998	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9176963	OTHER	IL	DORAL PROVIDER NUMBER

General Provider Information

NPI Number	:	1700876661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALEXANDRA ANDERSON D.D.S

Provider Business Mailing Address
First Line	:	P.O BOX 564
Second Line	:
City	:	LAKE BLUFF
State	:	IL
Zip	:	60044
Country	:	US
Telephone Number	:	773-465-4500
Fax Number	:	773-353-2102

Provider Business Practice Location Address
First Line	:	1514 W DEVON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660
Country	:	US
Telephone Number	:	773-465-4500
Fax Number	:	773-353-2102

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	11/07/2013

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