Provider Demographics
NPI:1346337714
Name:SORENSEN, ERIC JUSTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JUSTIN
Last Name:SORENSEN
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 1:762 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-3413
Mailing Address - Country:US
Mailing Address - Phone:775-738-1553
Mailing Address - Fax:775-738-5934
Practice Address - Street 1:762 14TH ST
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-3413
Practice Address - Country:US
Practice Address - Phone:775-738-1553
Practice Address - Fax:775-738-5934
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV47921223G0001X, 122300000X
NE65421223G0001X
UT325161122300000X
TX24285122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100510329Medicaid
NV1346337714Medicaid