Provider Demographics
NPI:1871649137
Name:OUTERICKA, EDITA (DMD)
Entity Type:Individual
Prefix:
First Name:EDITA
Middle Name:
Last Name:OUTERICKA
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 1:3 BRADFORD ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375-1453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 TECHNOLOGY PARK DR
Practice Address - Street 2:
Practice Address - City:BOURNE
Practice Address - State:MA
Practice Address - Zip Code:02532-8336
Practice Address - Country:US
Practice Address - Phone:508-759-2724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA204711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice