1821420720 NPI number — ERICKSON DMD PC

Table of content: (NPI 1821420720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821420720 NPI number — ERICKSON DMD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ERICKSON DMD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821420720
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASPER
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82602-2190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-237-8419
Provider Business Mailing Address Fax Number:
307-234-4912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
932 S DAVID ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASPER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82601-3738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-237-8419
Provider Business Practice Location Address Fax Number:
307-234-4912
Provider Enumeration Date:
08/01/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ERICKSON
Authorized Official First Name:
KOLTON
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
307-237-8419

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  1329 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1770893414 . This is a "NPI" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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