MEDICARE: DR. ERIC DAVID NORDBERG DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DE60520428	WA

General Provider Information

NPI Number	:	1851605448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC DAVID NORDBERG DDS

Provider Business Mailing Address
First Line	:	8102 66TH AVENUE CT E
Second Line	:
City	:	PUYALLUP
State	:	WA
Zip	:	98371-5593
Country	:	US
Telephone Number	:	253-881-1896
Fax Number	:	253-446-7117

Provider Business Practice Location Address
First Line	:	11025 CANYON RD E STE C
Second Line	:
City	:	PUYALLUP
State	:	WA
Zip	:	98373-4268
Country	:	US
Telephone Number	:	253-881-1896
Fax Number	:	253-446-7117

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2010
Last Update Date	:	02/28/2019

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