Healthcare Provider Details

I. General information

NPI: 1336137157
Provider Name (Legal Business Name): MARK F. ERICKSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

383 S SCHMALE RD
CAROL STREAM IL
60188-2756
US

IV. Provider business mailing address

8685 TIMBER RIDGE DR
BURR RIDGE IL
60527-5694
US

V. Phone/Fax

Practice location:
  • Phone: 630-909-0500
  • Fax: 630-909-0800
Mailing address:
  • Phone: 630-850-7780
  • Fax: 630-850-7781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: