Provider Demographics
NPI:1912015090
Name:ERICKSON, TIMOTHY CARL (DDS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:CARL
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-0218
Mailing Address - Country:US
Mailing Address - Phone:218-834-5616
Mailing Address - Fax:218-834-9155
Practice Address - Street 1:508 SECOND AVE
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-2007
Practice Address - Country:US
Practice Address - Phone:218-834-5616
Practice Address - Fax:218-834-9155
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN57221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice