Provider Demographics
NPI:1376621219
Name:SWENSON, REBECCA (DDS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:SWENSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 C WEST MASON STREET
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-4058
Mailing Address - Country:US
Mailing Address - Phone:920-499-7159
Mailing Address - Fax:
Practice Address - Street 1:1800 C WEST MASON STREET
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4058
Practice Address - Country:US
Practice Address - Phone:920-499-7159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3682-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist