Provider Demographics
NPI:1215352000
Name:ERICKSON FAMILY DENTISTRY PLLC
Entity type:Organization
Organization Name:ERICKSON FAMILY DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-586-5234
Mailing Address - Street 1:206 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VENUS
Mailing Address - State:TX
Mailing Address - Zip Code:76084
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:206 S MAIN ST
Practice Address - Street 2:
Practice Address - City:VENUS
Practice Address - State:TX
Practice Address - Zip Code:76084
Practice Address - Country:US
Practice Address - Phone:972-366-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-03
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9729122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty