Healthcare Provider Details

I. General information

NPI: 1902004666
Provider Name (Legal Business Name): ERIC CARL EDSTROM D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2780 STATE ST SUITE 4
SANTA BARBARA CA
93105-5518
US

IV. Provider business mailing address

2780 STATE ST SUITE 4
SANTA BARBARA CA
93105-5518
US

V. Phone/Fax

Practice location:
  • Phone: 805-687-5561
  • Fax: 805-687-0810
Mailing address:
  • Phone: 805-687-5561
  • Fax: 805-687-0810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number36237
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: