Provider Demographics
NPI:1518998178
Name:SWANSON, REGINALD (DMD)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:SWANSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 AVE. W PRATT CITY
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35214-5028
Mailing Address - Country:US
Mailing Address - Phone:205-798-1697
Mailing Address - Fax:205-791-0165
Practice Address - Street 1:100 AVE. W PRATT CITY
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35214-5028
Practice Address - Country:US
Practice Address - Phone:205-798-1697
Practice Address - Fax:205-791-0165
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL37091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL96807OtherBLUE CROSS BLUE SHIELD
MS00109052Medicaid