Provider Demographics
NPI:1497867626
Name:ANDERSON, TODD MATHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:MATHEW
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 BETHANY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178
Mailing Address - Country:US
Mailing Address - Phone:815-895-3000
Mailing Address - Fax:815-895-0505
Practice Address - Street 1:1675 BETHANY RD
Practice Address - Street 2:SUITE A
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178
Practice Address - Country:US
Practice Address - Phone:815-895-3000
Practice Address - Fax:815-895-0505
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210015631223S0112X
IL19022431204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
L97550Medicare ID - Type Unspecified
U27021Medicare UPIN