Provider Demographics
NPI:1972549145
Name:NORDSTROM, ERIC DALE (DDS)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:DALE
Last Name:NORDSTROM
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 1:309 LAKELAND DRIVE SE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-4099
Mailing Address - Country:US
Mailing Address - Phone:320-235-1075
Mailing Address - Fax:320-235-1079
Practice Address - Street 1:309 LAKELAND DRIVE SE
Practice Address - Street 2:SUITE 1
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-4099
Practice Address - Country:US
Practice Address - Phone:320-235-1075
Practice Address - Fax:320-235-1079
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10397122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist