Provider Demographics
NPI:1235205238
Name:SWANSON, LARRY DEAN (DDS)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DEAN
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 1:427 NORTH BROADWAY STREET
Mailing Address - Street 2:
Mailing Address - City:WAHOO
Mailing Address - State:NE
Mailing Address - Zip Code:68066
Mailing Address - Country:US
Mailing Address - Phone:402-443-4989
Mailing Address - Fax:402-443-1240
Practice Address - Street 1:427 NORTH BROADWAY STREET
Practice Address - Street 2:
Practice Address - City:WAHOO
Practice Address - State:NE
Practice Address - Zip Code:68066
Practice Address - Country:US
Practice Address - Phone:402-443-4989
Practice Address - Fax:402-443-1240
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE51651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47069066500Medicaid
NE05662OtherBLUE CROSS BLUE SHIELD