Provider Demographics
NPI:1679697676
Name:ANDERSON, BRETT DONALD (DENTIST)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:DONALD
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 W TOUHY AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4205
Mailing Address - Country:US
Mailing Address - Phone:847-692-2303
Mailing Address - Fax:847-692-2684
Practice Address - Street 1:318 W TOUHY AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4205
Practice Address - Country:US
Practice Address - Phone:847-692-2303
Practice Address - Fax:847-692-2684
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19023301122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist