Provider Demographics
NPI:1114930922
Name:ERICKSON, GARY LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
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 1:424 WEST 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066
Mailing Address - Country:US
Mailing Address - Phone:651-388-5492
Mailing Address - Fax:
Practice Address - Street 1:424 WEST 5TH ST
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066
Practice Address - Country:US
Practice Address - Phone:651-388-5492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8996122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist