Basic Information
Provider Information | |||||||||
NPI: | 1093724957 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ERICKSON | ||||||||
FirstName: | LEA | ||||||||
MiddleName: | ELLA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS, MSPH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WEBB | ||||||||
OtherFirstName: | LEA | ||||||||
OtherMiddleName: | ELLA | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DDS | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7165 S 2780 E | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841214152 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019430954 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | VASLCHCS (160) | ||||||||
Address2: | 500 FOOTHILL | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841480001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015821565 | ||||||||
FaxNumber: | 8015841251 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/07/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 139261-9923 | UT | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.