Provider Demographics
NPI:1093886525
Name:HALLIE, ERICK MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERICK
Middle Name:MICHAEL
Last Name:HALLIE
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 1:34536 WILDERNESSA RD
Mailing Address - Street 2:
Mailing Address - City:DEER RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:56636-3075
Mailing Address - Country:US
Mailing Address - Phone:218-326-6155
Mailing Address - Fax:
Practice Address - Street 1:520 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2560
Practice Address - Country:US
Practice Address - Phone:218-326-2901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice