Provider Demographics
NPI:1083934905
Name:THEISEN, ERIKA MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIKA
Middle Name:MARIE
Last Name:THEISEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ERIKA
Other - Middle Name:MARIE
Other - Last Name:WETZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:22 2ND AVE S
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-1408
Mailing Address - Country:US
Mailing Address - Phone:320-252-7806
Mailing Address - Fax:320-252-9044
Practice Address - Street 1:22 2ND AVE S
Practice Address - Street 2:
Practice Address - City:SAUK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56379-1408
Practice Address - Country:US
Practice Address - Phone:320-252-7806
Practice Address - Fax:320-252-9044
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND127951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice