Provider Demographics
NPI:1841763513
Name:SWAN PEDIATRIC DENTAL
Entity Type:Organization
Organization Name:SWAN PEDIATRIC DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SWAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-718-8348
Mailing Address - Street 1:1177 W 1960 N
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-4039
Mailing Address - Country:US
Mailing Address - Phone:801-718-8348
Mailing Address - Fax:
Practice Address - Street 1:601 N STATE ROAD 198
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:UT
Practice Address - Zip Code:84653-4504
Practice Address - Country:US
Practice Address - Phone:801-423-7969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-06
Last Update Date:2019-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1336405315Medicaid