Provider Demographics
NPI:1114042710
Name:ERICKSON, GARY S (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
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 1:430 25TH STREET
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601
Mailing Address - Country:US
Mailing Address - Phone:218-751-8626
Mailing Address - Fax:
Practice Address - Street 1:430 25TH STREET NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-0000
Practice Address - Country:US
Practice Address - Phone:218-751-8626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8049122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist