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General NPI Number Information
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NPI Number | 1780175307
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Entity Type | Organization
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Legal Business Name | ERICSON DENTAL INC
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Dates
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Enumeration Date | 05/21/2018
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Last Update Date | 05/21/2018
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Provider Practice Location Address
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Address Line | 1201 E OCEAN AVE STE G
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City | LOMPOC
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State | CA
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Zip | 93436-7083
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Country | US
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Telephone | 805-735-2702
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Fax |
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Provider Business Mailing Address
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Address Line | 1201 E OCEAN AVE STE G
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City | LOMPOC
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State | CA
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Zip | 93436-7083
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Country | US
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Telephone | 805-735-2702
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | STEN ERICSON
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Credential | DDS
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Telephone | 805-708-7866
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 57188
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License Number State | CA
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