Provider Demographics
NPI:1003269408
Name:ERICKSON, JUSTIN (DDS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
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 1:4001 LAKE OTIS PKWY
Mailing Address - Street 2:#200
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5200
Mailing Address - Country:US
Mailing Address - Phone:907-222-0400
Mailing Address - Fax:
Practice Address - Street 1:4001 LAKE OTIS PKWY
Practice Address - Street 2:#200
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5200
Practice Address - Country:US
Practice Address - Phone:907-222-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60653265122300000X
AK110578122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist