Provider Demographics
NPI:1326268616
Name:ERICSON, PAUL (DMD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:ERICSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 DEERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983-3324
Mailing Address - Country:US
Mailing Address - Phone:518-891-3856
Mailing Address - Fax:
Practice Address - Street 1:15 DEERWOOD LN
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-3324
Practice Address - Country:US
Practice Address - Phone:518-891-3856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0329701122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00583702Medicaid