Provider Demographics
NPI:1528216256
Name:ERICKSON, IAN MATTHEW (DMD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:MATTHEW
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 HASKELL ST APT 3
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-2395
Mailing Address - Country:US
Mailing Address - Phone:971-237-0096
Mailing Address - Fax:
Practice Address - Street 1:1224 NE 7TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1424
Practice Address - Country:US
Practice Address - Phone:541-476-3419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-06
Last Update Date:2008-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9158122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist