Provider Demographics
NPI:1053306985
Name:SWAN, JIMMY DEAN II (DDS)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:DEAN
Last Name:SWAN
Suffix:II
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 1:6401 NW EXPRESSWAY
Mailing Address - Street 2:SUITE 132
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5170
Mailing Address - Country:US
Mailing Address - Phone:405-728-2828
Mailing Address - Fax:405-720-2929
Practice Address - Street 1:6401 NW EXPRESSWAY
Practice Address - Street 2:SUITE 132
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-5170
Practice Address - Country:US
Practice Address - Phone:405-728-2828
Practice Address - Fax:405-720-2929
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK54981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK030704OtherTRICARE CONCORDIA
OK2305498OtherDELTA