Provider Demographics
NPI:1821420720
Name:ERICKSON DMD PC
Entity Type:Organization
Organization Name:ERICKSON DMD PC
Other - Org Name:307 ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KOLTON
Authorized Official - Middle Name:K
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:307-237-8419
Mailing Address - Street 1:PO BOX 2190
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82602-2190
Mailing Address - Country:US
Mailing Address - Phone:307-237-8419
Mailing Address - Fax:307-234-4912
Practice Address - Street 1:932 S DAVID ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-3738
Practice Address - Country:US
Practice Address - Phone:307-237-8419
Practice Address - Fax:307-234-4912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY13291223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1770893414OtherNPI