Provider Demographics
NPI:1215233168
Name:ERICKSON, JILL RENEE (RDH)
Entity type:Individual
Prefix:MISS
First Name:JILL
Middle Name:RENEE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3114
Mailing Address - Country:US
Mailing Address - Phone:480-220-5205
Mailing Address - Fax:
Practice Address - Street 1:29 BLACK COAL DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514
Practice Address - Country:US
Practice Address - Phone:307-332-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH05665124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist