Provider Demographics
NPI:1154797504
Name:SWENSON, DANE THOMAS
Entity type:Individual
Prefix:
First Name:DANE
Middle Name:THOMAS
Last Name:SWENSON
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:USA DENTAC
Mailing Address - Street 2:BLDG 38717 38TH STREET
Mailing Address - City:FT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5660
Mailing Address - Country:US
Mailing Address - Phone:706-787-6927
Mailing Address - Fax:706-787-2082
Practice Address - Street 1:851 S RAMPART BLVD STE 240
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-4888
Practice Address - Country:US
Practice Address - Phone:702-508-6714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9410763-99211223G0001X, 1223P0300X
NVS4-122C1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No1223G0001XDental ProvidersDentistGeneral Practice