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General NPI Number Information
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NPI Number | 1821420720
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Entity Type | Organization
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Legal Business Name | ERICKSON DMD PC
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Dates
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Enumeration Date | 08/01/2013
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Last Update Date | 08/01/2013
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Provider Practice Location Address
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Address Line | 932 S DAVID ST
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City | CASPER
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State | WY
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Zip | 82601-3738
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Country | US
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Telephone | 307-237-8419
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Fax | 307-234-4912
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Provider Business Mailing Address
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Address Line | PO BOX 2190
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City | CASPER
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State | WY
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Zip | 82602-2190
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Country | US
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Telephone | 307-237-8419
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Fax | 307-234-4912
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KOLTON K ERICKSON
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Credential | D.M.D.
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Telephone | 307-237-8419
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 1329
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License Number State | WY
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