Provider Demographics
NPI:1952374761
Name:ERICSON, MARK SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:SCOTT
Last Name:ERICSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Mailing Address - Street 1:1320 APPLE AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-1552
Mailing Address - Country:US
Mailing Address - Phone:360-870-9097
Mailing Address - Fax:510-582-8147
Practice Address - Street 1:1320 APPLE AVE STE 104
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-1552
Practice Address - Country:US
Practice Address - Phone:360-870-9097
Practice Address - Fax:510-582-8147
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ22DI022303001223S0112X
TX236911223S0112X
CA600841223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery