Provider Demographics
NPI:1962540518
Name:SWENSEN, RUSSELL CRAIG (DDS)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:CRAIG
Last Name:SWENSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:R
Other - Middle Name:CRAIG
Other - Last Name:SWENSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:4316 CRYSTAL LANE LOOP SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-5293
Mailing Address - Country:US
Mailing Address - Phone:253-841-1191
Mailing Address - Fax:
Practice Address - Street 1:3928 10TH ST SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2188
Practice Address - Country:US
Practice Address - Phone:253-848-1558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA56801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5031182OtherDSHS