Provider Demographics
NPI:1932543121
Name:LUND, ERICK JORDAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERICK
Middle Name:JORDAN
Last Name:LUND
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4651 W 13400 S STE 110
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-6483
Mailing Address - Country:US
Mailing Address - Phone:801-515-5858
Mailing Address - Fax:801-515-5859
Practice Address - Street 1:4651 W 13400 S STE 110
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-6483
Practice Address - Country:US
Practice Address - Phone:801-515-5858
Practice Address - Fax:801-515-5859
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8345190-99221223G0001X
UT83451901223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1083298525Medicaid