Provider Demographics
NPI:1508933789
Name:ERICKSON, CHARLES MERLE (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MERLE
Last Name:ERICKSON
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:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412
Mailing Address - Country:US
Mailing Address - Phone:231-924-0040
Mailing Address - Fax:231-924-5899
Practice Address - Street 1:16 W SHERIDAN
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412
Practice Address - Country:US
Practice Address - Phone:231-924-0040
Practice Address - Fax:231-924-5899
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010093231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice