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General NPI Number Information
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NPI Number | 1861057622
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Entity Type | Individual
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Provider Name | JAIMIE ERICKSON
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Gender | Female
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Dates
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Enumeration Date | 05/07/2019
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Last Update Date | 05/07/2019
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Provider Practice Location Address
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Address Line | 1215 E 6TH ST
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City | MOSCOW
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State | ID
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Zip | 83843-3705
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Country | US
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Telephone | 208-610-5103
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Fax |
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Provider Business Mailing Address
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Address Line | 2056 W 12015 S
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City | RIVERTON
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State | UT
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Zip | 84065-7518
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Country | US
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Telephone | 208-610-5103
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D-5020
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License Number State | ID
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