Provider Demographics
NPI:1568486769
Name:ERICKSON, KIM L (DDS)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:L
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 1:4500 CASCADE RD SE
Mailing Address - Street 2:SUITE #208
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3665
Mailing Address - Country:US
Mailing Address - Phone:616-977-5000
Mailing Address - Fax:616-977-0020
Practice Address - Street 1:4500 CASCADE RD SE
Practice Address - Street 2:SUITE #208
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3665
Practice Address - Country:US
Practice Address - Phone:616-977-5000
Practice Address - Fax:616-977-0020
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKE0115531223P0106X, 1223S0112X, 1223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Not Answered1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT82820Medicare UPIN
MIP2785001Medicare ID - Type Unspecified