Provider Demographics
NPI:1972001196
Name:ERICSON COMMUNITY CARE DENTAL CLINIC LOMPOC INC
Entity Type:Organization
Organization Name:ERICSON COMMUNITY CARE DENTAL CLINIC LOMPOC INC
Other - Org Name:COMMUNITY CARE DENTAL GROUP LOMPOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNDER
Authorized Official - Prefix:
Authorized Official - First Name:STEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:805-708-7866
Mailing Address - Street 1:1201 E OCEAN AVE STE G
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-7083
Mailing Address - Country:US
Mailing Address - Phone:805-735-2702
Mailing Address - Fax:
Practice Address - Street 1:1201 E OCEAN AVE STE G
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-7083
Practice Address - Country:US
Practice Address - Phone:805-735-2702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental