Provider Demographics
NPI:1497922041
Name:RUSSELL ERICKSON DDS PC
Entity Type:Organization
Organization Name:RUSSELL ERICKSON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-353-1471
Mailing Address - Street 1:13530 SE 97TH AVE
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-7691
Mailing Address - Country:US
Mailing Address - Phone:503-353-1471
Mailing Address - Fax:503-353-1473
Practice Address - Street 1:13530 SE 97TH AVE
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-7691
Practice Address - Country:US
Practice Address - Phone:503-353-1471
Practice Address - Fax:503-353-1473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6120261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental