Provider Demographics
NPI:1932537784
Name:SWAIN, KELLI
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:SWAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11104 23RD PL NE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-8415
Mailing Address - Country:US
Mailing Address - Phone:425-231-8676
Mailing Address - Fax:
Practice Address - Street 1:11104 23RD PL NE
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-8415
Practice Address - Country:US
Practice Address - Phone:425-231-8676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAD160237537126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
D160237537OtherDENTAL PROVIDER