Provider Demographics
NPI:1750057402
Name:VAN ETTA, ERICA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERICA
Middle Name:
Last Name:VAN ETTA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14693 OLDENBERG CT
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-1013
Mailing Address - Country:US
Mailing Address - Phone:571-232-7887
Mailing Address - Fax:
Practice Address - Street 1:1320 N ZARAGOZA RD STE 110
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7930
Practice Address - Country:US
Practice Address - Phone:915-262-4640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37753122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist