Provider Demographics
NPI:1992441117
Name:KARACHEBAN, ERIKSON
Entity type:Individual
Prefix:
First Name:ERIKSON
Middle Name:
Last Name:KARACHEBAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 SW 66TH AVE APT 3302
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6025
Mailing Address - Country:US
Mailing Address - Phone:503-881-9361
Mailing Address - Fax:
Practice Address - Street 1:250 E INTERNATIONAL SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-2340
Practice Address - Country:US
Practice Address - Phone:386-626-3296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice