Provider Demographics
NPI:1407923915
Name:SWANSON AND ASSOCIATES FAMILY DENTISTRY, INC.
Entity Type:Organization
Organization Name:SWANSON AND ASSOCIATES FAMILY DENTISTRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-644-6951
Mailing Address - Street 1:P.O. BOX 379
Mailing Address - Street 2:410 E. WASHINGTON ST.
Mailing Address - City:SLINGER
Mailing Address - State:WI
Mailing Address - Zip Code:53086
Mailing Address - Country:US
Mailing Address - Phone:262-644-6951
Mailing Address - Fax:262-644-6825
Practice Address - Street 1:410 E. WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:SLINGER
Practice Address - State:WI
Practice Address - Zip Code:53086
Practice Address - Country:US
Practice Address - Phone:262-644-6951
Practice Address - Fax:262-644-6825
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SWANSON AND ASSOCIATES FAMILY DENTISTRY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-29
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31371223G0001X
WI6881-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38395700OtherMEDICAID GROUP PROVIDER
WI3137OtherDELTA
WI33451600Medicaid