Basic Information
| Provider Information | |||||||||
| NPI: | 1366889479 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WU | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 1ST ST SW | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072842511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5900 WATERLOO RD STE 220 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210452638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106308189 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2013 | ||||||||
| LastUpdateDate: | 03/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204E00000X | D13265 | MN | Y | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | ENROLLED | 05 | MN | MEDICAID |