Provider Demographics
NPI:1891228342
Name:SWETT TAPIA, JORGE RICARDO
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:RICARDO
Last Name:SWETT TAPIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 W DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:MI
Mailing Address - Zip Code:49045-1106
Mailing Address - Country:US
Mailing Address - Phone:269-201-5831
Mailing Address - Fax:
Practice Address - Street 1:321 W DELAWARE ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:MI
Practice Address - Zip Code:49045
Practice Address - Country:US
Practice Address - Phone:269-201-5831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI2901022808122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program