Provider Demographics
NPI:1811265143
Name:ERICKSEN, ANDREW G (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:G
Last Name:ERICKSEN
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 1:4543 S SUNCREST DR
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4316
Mailing Address - Country:US
Mailing Address - Phone:801-633-3183
Mailing Address - Fax:
Practice Address - Street 1:2160 E 4500 S STE 3
Practice Address - Street 2:SAME
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4499
Practice Address - Country:US
Practice Address - Phone:801-277-9213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT799933399221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice