Provider Demographics
NPI:1528335973
Name:ERICKSON, CHAD WAYNE (DDS)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:WAYNE
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 1:577 STERNBERG AVE
Mailing Address - Street 2:
Mailing Address - City:FORT EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23604-1526
Mailing Address - Country:US
Mailing Address - Phone:435-764-5125
Mailing Address - Fax:
Practice Address - Street 1:2601 C AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:VA
Practice Address - Zip Code:23801-1717
Practice Address - Country:US
Practice Address - Phone:435-764-5125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014134211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice