=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275669830
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TY ERICKSON DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2007
-----------------------------------------------------
Last Update Date | 11/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4855 MILLS CIVIC PKWY STE 201
-----------------------------------------------------
City | WEST DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50265-5268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-577-4488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4855 MILLS CIVIC PKWY STE 201
-----------------------------------------------------
City | WEST DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50265-5268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-577-4488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 07867
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------