Provider Demographics
NPI:1275669830
Name:ERICKSON, TY (DDS)
Entity Type:Individual
Prefix:DR
First Name:TY
Middle Name:
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 1:4855 MILLS CIVIC PKWY STE 201
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-5268
Mailing Address - Country:US
Mailing Address - Phone:515-577-4488
Mailing Address - Fax:
Practice Address - Street 1:4855 MILLS CIVIC PKWY STE 201
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-5268
Practice Address - Country:US
Practice Address - Phone:515-577-4488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA078671223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics