Provider Demographics
NPI:1982792719
Name:AMUNDSON, ERIC (DDS)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:AMUNDSON
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 1:2810 SHARER RD STE 17
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-2107
Mailing Address - Country:US
Mailing Address - Phone:850-385-5188
Mailing Address - Fax:
Practice Address - Street 1:2810 SHARER RD STE 17
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32312-2107
Practice Address - Country:US
Practice Address - Phone:850-385-5188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15271122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist