Provider Demographics
NPI:1962513408
Name:KNUTSON, ERIC JON (DDS)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JON
Last Name:KNUTSON
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 1:9712 FAIR OAKS BLVD
Mailing Address - Street 2:#D
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-7032
Mailing Address - Country:US
Mailing Address - Phone:916-966-0835
Mailing Address - Fax:916-966-3921
Practice Address - Street 1:9712 FAIR OAKS BLVD
Practice Address - Street 2:#D
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-7032
Practice Address - Country:US
Practice Address - Phone:916-966-0835
Practice Address - Fax:916-966-3921
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680091765OtherFEDERAL TAX ID