Provider Demographics
NPI:1528150133
Name:SWAIN, EDWARD KENNETH JR (DMD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:KENNETH
Last Name:SWAIN
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:750 PARK AVE
Mailing Address - Street 2:SUITE 1A/1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4252
Mailing Address - Country:US
Mailing Address - Phone:212-861-7979
Mailing Address - Fax:212-861-5018
Practice Address - Street 1:750 PARK AVE
Practice Address - Street 2:SUITE 1A/1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4252
Practice Address - Country:US
Practice Address - Phone:212-861-7979
Practice Address - Fax:212-861-5018
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0288711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00284340Medicaid
NY13-3579806OtherTAX ID
NY13-3579806OtherTAX ID
NYT49689Medicare UPIN