Provider Demographics
NPI:1629104757
Name:SWANSON, LOREN CHARLES (DDS)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:CHARLES
Last Name:SWANSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 OREGON ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-7060
Mailing Address - Country:US
Mailing Address - Phone:920-231-8120
Mailing Address - Fax:920-231-8296
Practice Address - Street 1:2215 OREGON ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-7060
Practice Address - Country:US
Practice Address - Phone:920-231-8120
Practice Address - Fax:920-231-8296
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50013010151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33614900Medicaid