Basic Information
Provider Information
NPI: 1033556105
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ERICKSON
FirstName: JAY
MiddleName: M
NamePrefix: DR.
NameSuffix:  
Credential: D.D.S.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1509 EMERALD PARKWAY SUITE 105
Address2:  
City: COLLEGE STATION
State: TX
PostalCode: 77845
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1509 EMERALD PKWY STE 105
Address2:  
City: COLLEGE STATION
State: TX
PostalCode: 778455502
CountryCode: US
TelephoneNumber: 9796968681
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/30/2013
LastUpdateDate: 05/30/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X28891TXY Dental ProvidersDentist 

No ID Information.


Home