Provider Demographics
NPI:1902004666
Name:EDSTROM, ERIC CARL (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:CARL
Last Name:EDSTROM
Suffix:
Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:2780 STATE ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-5518
Mailing Address - Country:US
Mailing Address - Phone:805-687-5561
Mailing Address - Fax:805-687-0810
Practice Address - Street 1:2780 STATE ST
Practice Address - Street 2:SUITE 4
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-5518
Practice Address - Country:US
Practice Address - Phone:805-687-5561
Practice Address - Fax:805-687-0810
Is Sole Proprietor?:No
Enumeration Date:2007-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA362371223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics