Provider Demographics
NPI:1588920573
Name:SWANSON, BRIAN C (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:C
Last Name:SWANSON
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 1:410 E WASHINGTON ST
Mailing Address - Street 2:P.O. BOX 379
Mailing Address - City:SLINGER
Mailing Address - State:WI
Mailing Address - Zip Code:53086-9650
Mailing Address - Country:US
Mailing Address - Phone:262-644-6951
Mailing Address - Fax:
Practice Address - Street 1:410 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SLINGER
Practice Address - State:WI
Practice Address - Zip Code:53086-9650
Practice Address - Country:US
Practice Address - Phone:262-644-6951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6881-15122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program