Provider Demographics
NPI:1447408463
Name:KECK-ERICKSON, NICOLE LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LEE
Last Name:KECK-ERICKSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:LEE
Other - Last Name:KECK-ERICKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:906 ROYAL CT
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6139
Mailing Address - Country:US
Mailing Address - Phone:541-779-2634
Mailing Address - Fax:541-779-3282
Practice Address - Street 1:906 ROYAL CT
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6139
Practice Address - Country:US
Practice Address - Phone:541-779-2634
Practice Address - Fax:541-779-3282
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9139122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist