Provider Demographics
NPI:1154303717
Name:SWANSON, JUSTIN SKJEI (DDS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:SKJEI
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 1:12450 WAYZATA BLVD
Mailing Address - Street 2:214
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1934
Mailing Address - Country:US
Mailing Address - Phone:952-545-2838
Mailing Address - Fax:952-545-7649
Practice Address - Street 1:12450 WAYZATA BLVD
Practice Address - Street 2:214
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1934
Practice Address - Country:US
Practice Address - Phone:952-545-2838
Practice Address - Fax:952-545-7649
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND115391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice