Provider Demographics
NPI:1972981025
Name:ERICSON, KELTON (DMD, MD)
Entity type:Individual
Prefix:
First Name:KELTON
Middle Name:
Last Name:ERICSON
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64369
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85728-4369
Mailing Address - Country:US
Mailing Address - Phone:602-758-9009
Mailing Address - Fax:
Practice Address - Street 1:3382 E SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-3936
Practice Address - Country:US
Practice Address - Phone:602-758-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZD0116861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program