Provider Demographics
NPI:1326779430
Name:ERICKSON, BRAD W JR (DDS)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:W
Last Name:ERICKSON
Suffix:JR
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 1:123 N 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2912
Mailing Address - Country:US
Mailing Address - Phone:208-914-0971
Mailing Address - Fax:
Practice Address - Street 1:11110 FORT ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-2183
Practice Address - Country:US
Practice Address - Phone:402-492-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-100061223G0001X
NE78391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice