Healthcare Provider Details

I. General information

NPI: 1215794060
Provider Name (Legal Business Name): ERICKSON ORAL & MAXILLOFACIAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2024
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

383 S SCHMALE RD
CAROL STREAM IL
60188-2756
US

IV. Provider business mailing address

383 S SCHMALE RD
CAROL STREAM IL
60188-2756
US

V. Phone/Fax

Practice location:
  • Phone: 630-909-0500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK F ERICKSON
Title or Position: OWNER/SURGEON
Credential: DDS
Phone: 630-308-9902