Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 110578 | AK |
N | 122300000X | Dentist | 60653265 | WA |
NPI | 1003269408 |
---|---|
Provider Name | Justin Erickson |
First Address | Anchorage, AK 99508-5200 |
Second Address | Anchorage, AK 99508-5200 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2016 |
Last Update Date | 20/07/2016 |