Provider Demographics
NPI:1881674042
Name:ERICKSON, KIM K (DMD, MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:K
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 SW 10TH AVE SUITE 808
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205
Mailing Address - Country:US
Mailing Address - Phone:503-289-9621
Mailing Address - Fax:503-289-2930
Practice Address - Street 1:511 10TH AVE SUITE 808
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-4661
Practice Address - Country:US
Practice Address - Phone:503-289-9621
Practice Address - Fax:503-289-2930
Is Sole Proprietor?:No
Enumeration Date:2006-01-21
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD69051223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery