Provider Demographics
NPI:1013033794
Name:SWANSON, BRADLEY RICHARD (DDS MSD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:RICHARD
Last Name:SWANSON
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 S. TWYCKENHAM DRIVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:54505 26TH STREET
Practice Address - Street 2:UNIT E
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635
Practice Address - Country:US
Practice Address - Phone:574-807-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010670A1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics