Provider Demographics
NPI:1821175928
Name:ANDERSON, TERRY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:L
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 1:111 W WESLEY ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-5136
Mailing Address - Country:US
Mailing Address - Phone:630-668-1420
Mailing Address - Fax:630-668-1562
Practice Address - Street 1:111 W WESLEY ST
Practice Address - Street 2:SUITE 3
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5136
Practice Address - Country:US
Practice Address - Phone:630-668-1420
Practice Address - Fax:630-668-1562
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist