Provider Demographics
NPI:1407629215
Name:KERICKSEN DMD EAST PLLC
Entity Type:Organization
Organization Name:KERICKSEN DMD EAST PLLC
Other - Org Name:ELITE DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:406-591-7279
Mailing Address - Street 1:2376 MAIN ST STE 812
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59105-4018
Mailing Address - Country:US
Mailing Address - Phone:406-656-5200
Mailing Address - Fax:
Practice Address - Street 1:2376 MAIN ST STE 812
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59105-4018
Practice Address - Country:US
Practice Address - Phone:406-656-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-02
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty