Provider Demographics
NPI:1518076595
Name:SWANBERG-AUSTIN, BRIDGET RAQUEL (DDS)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:RAQUEL
Last Name:SWANBERG-AUSTIN
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:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:AZ
Mailing Address - Zip Code:85550-0208
Mailing Address - Country:US
Mailing Address - Phone:928-475-7354
Mailing Address - Fax:
Practice Address - Street 1:223 CIBEQUE CIRCLE ROAD
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:AZ
Practice Address - Zip Code:85550
Practice Address - Country:US
Practice Address - Phone:928-475-7354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0243741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ524571Medicaid