Provider Demographics
NPI:1649438268
Name:ERICKSON/AAMODT ORTHODONTICS PA
Entity type:Organization
Organization Name:ERICKSON/AAMODT ORTHODONTICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-405-1055
Mailing Address - Street 1:2130 CLIFF RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2485
Mailing Address - Country:US
Mailing Address - Phone:651-405-1055
Mailing Address - Fax:651-405-0727
Practice Address - Street 1:2130 CLIFF RD
Practice Address - Street 2:SUITE 220
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2485
Practice Address - Country:US
Practice Address - Phone:651-405-1055
Practice Address - Fax:651-405-0727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND95581223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty