Healthcare Provider Details

I. General information

NPI: 1457749285
Provider Name (Legal Business Name): JEFF W ERICKSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2015
Last Update Date: 01/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 E 700 S STE 301
ST GEORGE UT
84770-5741
US

IV. Provider business mailing address

640 E 700 S STE 301
ST GEORGE UT
84770-5741
US

V. Phone/Fax

Practice location:
  • Phone: 435-673-9661
  • Fax:
Mailing address:
  • Phone: 435-673-9661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number61864308903
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: