Provider Demographics
NPI:1336137157
Name:ERICKSON, MARK F (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:F
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8685 TIMBER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5694
Mailing Address - Country:US
Mailing Address - Phone:630-850-7780
Mailing Address - Fax:630-850-7781
Practice Address - Street 1:383 S SCHMALE RD
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-2756
Practice Address - Country:US
Practice Address - Phone:630-909-0500
Practice Address - Fax:630-909-0800
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT87161Medicare UPIN
IL204083Medicare ID - Type Unspecified