Provider Demographics
NPI:1720123995
Name:NORDSTROM, LEIF ERIK (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEIF
Middle Name:ERIK
Last Name:NORDSTROM
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 1:930 SUNNYSLOPE RD
Mailing Address - Street 2:SUITE D4
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-5619
Mailing Address - Country:US
Mailing Address - Phone:831-637-1675
Mailing Address - Fax:831-637-3987
Practice Address - Street 1:930 SUNNYSLOPE RD
Practice Address - Street 2:SUITE D4
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-5619
Practice Address - Country:US
Practice Address - Phone:831-637-1675
Practice Address - Fax:831-637-3987
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA524421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice