Provider Demographics
NPI:1134300890
Name:ERICKSON, JILL C
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:C
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 COTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CASSELTON
Mailing Address - State:ND
Mailing Address - Zip Code:58012-3824
Mailing Address - Country:US
Mailing Address - Phone:801-717-5997
Mailing Address - Fax:801-717-5997
Practice Address - Street 1:512 COTTONWOOD DR
Practice Address - Street 2:
Practice Address - City:CASSELTON
Practice Address - State:ND
Practice Address - Zip Code:58012-3824
Practice Address - Country:US
Practice Address - Phone:801-717-5997
Practice Address - Fax:801-717-5997
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant