Provider Demographics
NPI:1588086946
Name:SWAN DENTAL P.C.
Entity type:Organization
Organization Name:SWAN DENTAL P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SIDDHARTH
Authorized Official - Middle Name:
Authorized Official - Last Name:BANSAL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-872-8066
Mailing Address - Street 1:1460 S PEORIA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-2208
Mailing Address - Country:US
Mailing Address - Phone:352-872-8066
Mailing Address - Fax:
Practice Address - Street 1:23 W ROLLINS RD
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-1350
Practice Address - Country:US
Practice Address - Phone:847-740-4600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-19
Last Update Date:2014-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028736122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty