Provider Demographics
NPI:1831267913
Name:ERICKSON DENTAL GROUP
Entity type:Organization
Organization Name:ERICKSON DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:515-276-4981
Mailing Address - Street 1:7117 HICKMAN ROAD
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-4851
Mailing Address - Country:US
Mailing Address - Phone:515-276-4981
Mailing Address - Fax:515-276-4864
Practice Address - Street 1:7117 HICKMAN ROAD
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-4851
Practice Address - Country:US
Practice Address - Phone:515-276-4981
Practice Address - Fax:515-276-4864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08410122300000X
IA7898122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0037333Medicaid