Provider Demographics
NPI:1558515726
Name:ANDERSON, JOHN C
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 N GREENLEAF ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3393
Mailing Address - Country:US
Mailing Address - Phone:847-336-3200
Mailing Address - Fax:
Practice Address - Street 1:135 N GREENLEAF ST
Practice Address - Street 2:SUITE 202
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3393
Practice Address - Country:US
Practice Address - Phone:847-336-3200
Practice Address - Fax:847-336-1720
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL21-58711223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics