Healthcare Provider Details

I. General information

NPI: 1386606101
Provider Name (Legal Business Name): ERICK F CARLGREN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CALLE MEDICO SUITE 3
SANTA FE NM
87505-4785
US

IV. Provider business mailing address

2 CALLE MEDICO SUITE 3
SANTA FE NM
87505-4785
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-4592
  • Fax: 505-982-1612
Mailing address:
  • Phone: 505-982-4592
  • Fax: 505-982-1612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number1429
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: