Provider Demographics
NPI:1093724957
Name:ERICKSON, LEA ELLA (DDS, MSPH)
Entity Type:Individual
Prefix:DR
First Name:LEA
Middle Name:ELLA
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:DDS, MSPH
Other - Prefix:DR
Other - First Name:LEA
Other - Middle Name:ELLA
Other - Last Name:WEBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:7165 S 2780 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-4152
Mailing Address - Country:US
Mailing Address - Phone:801-943-0954
Mailing Address - Fax:
Practice Address - Street 1:VASLCHCS (160)
Practice Address - Street 2:500 FOOTHILL
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:801-584-1251
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT139261-99231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice