Healthcare Provider Details

I. General information

NPI: 1972872851
Provider Name (Legal Business Name): DR SVEN ERICKSON D D S P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2011
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 STONEGATE PARK
SAINT JOSEPH MI
49085-9130
US

IV. Provider business mailing address

3915 STONEGATE PARK
SAINT JOSEPH MI
49085-9130
US

V. Phone/Fax

Practice location:
  • Phone: 269-429-1515
  • Fax: 269-429-1538
Mailing address:
  • Phone: 269-429-1515
  • Fax: 269-429-1538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901015318
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. SVEN ALAN ERICKSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 269-429-1515