Provider Demographics
NPI:1811166614
Name:SWANSON, JAY IVOR (DDS,MD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:IVOR
Last Name:SWANSON
Suffix:
Gender:M
Credentials:DDS,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2191
Mailing Address - Country:US
Mailing Address - Phone:217-342-4444
Mailing Address - Fax:217-347-8928
Practice Address - Street 1:901 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2191
Practice Address - Country:US
Practice Address - Phone:217-342-4444
Practice Address - Fax:217-347-8928
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-26
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190193841223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019019384Medicaid
T87090Medicare UPIN