Healthcare Provider Details

I. General information

NPI: 1477823540
Provider Name (Legal Business Name): BRYAN KENT ERICSON D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2012
Last Update Date: 01/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 WEST 16TH STREET SUITE A
GREELEY CO
80634-6862
US

IV. Provider business mailing address

3400 WEST 16TH STREET SUITE A
GREELEY CO
80634-6862
US

V. Phone/Fax

Practice location:
  • Phone: 970-353-5826
  • Fax: 970-353-5829
Mailing address:
  • Phone: 970-353-5826
  • Fax: 970-356-5829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3041
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: