Provider Demographics
NPI:1073143731
Name:SWAN ORAL & FACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:SWAN ORAL & FACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSHI
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:863-688-1537
Mailing Address - Street 1:407 S KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-5301
Mailing Address - Country:US
Mailing Address - Phone:863-688-1537
Mailing Address - Fax:863-687-3418
Practice Address - Street 1:407 S KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5301
Practice Address - Country:US
Practice Address - Phone:863-688-1537
Practice Address - Fax:863-687-3418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN17708OtherSTATE LICENSE