Provider Demographics
NPI:1356320576
Name:SWIDERSKI, DAVID C (DDS, MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:SWIDERSKI
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4345
Mailing Address - Country:US
Mailing Address - Phone:503-581-0223
Mailing Address - Fax:
Practice Address - Street 1:1565 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4345
Practice Address - Country:US
Practice Address - Phone:503-581-0223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2009-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118191223S0112X
MN50992204E00000X
ORD90871223S0112X
ORMD29162204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN729449200Medicaid
MNP00052037OtherMEDICARE, RAILROAD
MNP00052037OtherMEDICARE, RAILROAD
MN190000743Medicare ID - Type Unspecified
MN729449200Medicaid