Provider Demographics
NPI:1134131311
Name:SWANSON, KRIS KEVIN (DDS)
Entity Type:Individual
Prefix:
First Name:KRIS
Middle Name:KEVIN
Last Name:SWANSON
Suffix:
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 1:1135 116TH AVE NE STE 580
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4628
Mailing Address - Country:US
Mailing Address - Phone:425-454-4434
Mailing Address - Fax:425-454-4386
Practice Address - Street 1:1135 116TH AVE NE STE 580
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4628
Practice Address - Country:US
Practice Address - Phone:425-454-4434
Practice Address - Fax:425-454-4386
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000062311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WABS0999372OtherCONTROLLED SUBSTANCE REG
WADE00006231OtherSTATE LICENSE