Provider Demographics
NPI:1447673348
Name:ANDERSON, TODD (DDS)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
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 1:5303 COLLEYVILLE BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-6129
Mailing Address - Country:US
Mailing Address - Phone:817-485-2111
Mailing Address - Fax:
Practice Address - Street 1:5303 COLLEYVILLE BLVD STE B
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-6129
Practice Address - Country:US
Practice Address - Phone:817-485-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX291411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice