Provider Demographics
NPI:1033127378
Name:ERICKSON, JON T (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:T
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 1:202 N PARK ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-2824
Mailing Address - Country:US
Mailing Address - Phone:507-238-2812
Mailing Address - Fax:507-235-8914
Practice Address - Street 1:202 N PARK ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-2824
Practice Address - Country:US
Practice Address - Phone:507-238-2812
Practice Address - Fax:507-235-8914
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10871122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist