Provider Demographics
NPI:1447209952
Name:SWANSON, RANDEL PAUL (DDS PHARM D)
Entity Type:Individual
Prefix:DR
First Name:RANDEL
Middle Name:PAUL
Last Name:SWANSON
Suffix:
Gender:M
Credentials:DDS PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225
Mailing Address - Country:US
Mailing Address - Phone:360-671-9979
Mailing Address - Fax:360-676-6206
Practice Address - Street 1:2000 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225
Practice Address - Country:US
Practice Address - Phone:360-671-9979
Practice Address - Fax:360-676-6206
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA76401223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5036348Medicaid
WA5018874Medicaid