Provider Demographics
NPI:1124683172
Name:ERICKSEN, KURT (DMD)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:
Last Name:ERICKSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2241 N ORCHARD WAY
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84045-3802
Mailing Address - Country:US
Mailing Address - Phone:406-591-7279
Mailing Address - Fax:
Practice Address - Street 1:5532 W HERRIMAN MAIN ST STE 210
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-5830
Practice Address - Country:US
Practice Address - Phone:801-446-9533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11260485-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist