Provider Demographics
NPI:1184931065
Name:JANSSON, ERICK A (DDS)
Entity type:Individual
Prefix:DR
First Name:ERICK
Middle Name:A
Last Name:JANSSON
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 1:1002 DIAMOND RDG STE 1500
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-7914
Mailing Address - Country:US
Mailing Address - Phone:573-298-4400
Mailing Address - Fax:573-616-1489
Practice Address - Street 1:1002 DIAMOND RDG STE 1500
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-7914
Practice Address - Country:US
Practice Address - Phone:573-298-4400
Practice Address - Fax:573-616-1489
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25599122300000X
MO20130125561223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist