Provider Demographics
NPI:1194807156
Name:ERICKSEN, STEPHEN L (DMD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
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 1:895 N 900 E
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-9183
Mailing Address - Country:US
Mailing Address - Phone:801-763-4164
Mailing Address - Fax:
Practice Address - Street 1:895 N 900 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-9183
Practice Address - Country:US
Practice Address - Phone:801-763-4164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKDEND1161122300000X
UT5314850-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD5568Medicaid
AK1161OtherLICENSED DENTIST
UT5314850-9922OtherLICENSED DENTIST