Provider Demographics
NPI:1699195669
Name:ERICSON, MOLLY PHYLLIS
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:PHYLLIS
Last Name:ERICSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 E CHICAGO ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-4725
Mailing Address - Country:US
Mailing Address - Phone:847-760-6100
Mailing Address - Fax:
Practice Address - Street 1:1350 E CHICAGO ST
Practice Address - Street 2:SUITE 4
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-4725
Practice Address - Country:US
Practice Address - Phone:847-760-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0300001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice