Provider Demographics
NPI:1619937307
Name:ERICKSON, MARK LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEE
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 1:113 N ANTHONY AVE
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:KS
Mailing Address - Zip Code:67003-2007
Mailing Address - Country:US
Mailing Address - Phone:620-842-3844
Mailing Address - Fax:
Practice Address - Street 1:113 N ANTHONY AVE
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:KS
Practice Address - Zip Code:67003-2007
Practice Address - Country:US
Practice Address - Phone:620-842-3844
Practice Address - Fax:620-842-4139
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS56291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS116666OtherBLUE CROSS BLUE SHIELD
KS4054684003Medicaid