Healthcare Provider Details

I. General information

NPI: 1184931065
Provider Name (Legal Business Name): ERICK A JANSSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 02/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 DIAMOND RDG STE 1500
JEFFERSON CITY MO
65109-7914
US

IV. Provider business mailing address

1002 DIAMOND RDG STE 1500
JEFFERSON CITY MO
65109-7914
US

V. Phone/Fax

Practice location:
  • Phone: 573-298-4400
  • Fax: 573-616-1489
Mailing address:
  • Phone: 573-298-4400
  • Fax: 573-616-1489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number25599
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2013012556
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: