Provider Demographics
NPI:1629374319
Name:ERICSSON, MARK
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:ERICSSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 N FEDERAL HWY
Mailing Address - Street 2:SUITE 176
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-5187
Mailing Address - Country:US
Mailing Address - Phone:561-470-4000
Mailing Address - Fax:
Practice Address - Street 1:4400 N FEDERAL HWY
Practice Address - Street 2:SUITE 176
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-5187
Practice Address - Country:US
Practice Address - Phone:561-479-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0011066122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist