=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245465723
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIK CHALLGREN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2009
-----------------------------------------------------
Last Update Date | 08/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 170 PROFESSIONAL CT
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47905-5153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-446-9606
-----------------------------------------------------
Fax | 765-446-9699
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 170 PROFESSIONAL CT
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47905-5153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-446-9606
-----------------------------------------------------
Fax | 765-446-9699
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 12011287A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------