Provider Demographics
NPI:1194736801
Name:SWANSTROM, GORDON BATES (DDS)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:BATES
Last Name:SWANSTROM
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 1:1430 TARA HILLS DR STE C
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2512
Mailing Address - Country:US
Mailing Address - Phone:510-724-8001
Mailing Address - Fax:510-724-1930
Practice Address - Street 1:1430 TARA HILLS DR STE C
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2512
Practice Address - Country:US
Practice Address - Phone:510-724-8001
Practice Address - Fax:510-724-1930
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA216541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice