Provider Demographics
NPI:1215265863
Name:ERICKSON, MART D (DDS)
Entity type:Individual
Prefix:DR
First Name:MART
Middle Name:D
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 NE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1424
Mailing Address - Country:US
Mailing Address - Phone:541-476-3419
Mailing Address - Fax:541-476-6985
Practice Address - Street 1:1224 NE 7TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1424
Practice Address - Country:US
Practice Address - Phone:541-476-3419
Practice Address - Fax:541-476-6985
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5491122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU29612Medicare UPIN