Provider Demographics
NPI:1043305626
Name:ERICKSON, KEITH ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ROBERT
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 CLIFF RD STE 220
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2487
Mailing Address - Country:US
Mailing Address - Phone:651-405-1055
Mailing Address - Fax:651-405-0727
Practice Address - Street 1:2130 CLIFF RD STE 220
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2487
Practice Address - Country:US
Practice Address - Phone:651-405-1055
Practice Address - Fax:651-405-0727
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN95581223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics