Healthcare Provider Details

I. General information

NPI: 1568486769
Provider Name (Legal Business Name): KIM L ERICKSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 CASCADE RD SE SUITE #208
GRAND RAPIDS MI
49546-3665
US

IV. Provider business mailing address

4500 CASCADE RD SE SUITE #208
GRAND RAPIDS MI
49546-3665
US

V. Phone/Fax

Practice location:
  • Phone: 616-977-5000
  • Fax: 616-977-0020
Mailing address:
  • Phone: 616-977-5000
  • Fax: 616-977-0020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberKE011553
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberKE011553
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License NumberKE011553
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: