Provider Demographics
NPI:1316175458
Name:ANDERSON, COLE (DMD,MS)
Entity type:Individual
Prefix:DR
First Name:COLE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DMD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2530
Mailing Address - Country:US
Mailing Address - Phone:217-383-3280
Mailing Address - Fax:217-383-7071
Practice Address - Street 1:602 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2530
Practice Address - Country:US
Practice Address - Phone:217-383-3280
Practice Address - Fax:217-383-7071
Is Sole Proprietor?:No
Enumeration Date:2009-06-28
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL018.0016991223S0112X
IL019.0281861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery