Provider Demographics
NPI:1083329635
Name:SWANSON, TIMOTHY RYAN
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:RYAN
Last Name:SWANSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26232 NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-4163
Mailing Address - Country:US
Mailing Address - Phone:805-657-6577
Mailing Address - Fax:
Practice Address - Street 1:12218 APPLE VALLEY RD STE 110
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-1704
Practice Address - Country:US
Practice Address - Phone:760-300-3678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1084401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice