Healthcare Provider Details

I. General information

NPI: 1972001196
Provider Name (Legal Business Name): ERICSON COMMUNITY CARE DENTAL CLINIC LOMPOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E OCEAN AVE STE G
LOMPOC CA
93436-7083
US

IV. Provider business mailing address

1201 E OCEAN AVE STE G
LOMPOC CA
93436-7083
US

V. Phone/Fax

Practice location:
  • Phone: 805-735-2702
  • Fax:
Mailing address:
  • Phone: 805-735-2702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEN ERICSON
Title or Position: OWNDER
Credential: DDS
Phone: 805-708-7866