MEDICARE: DR. JIMMY DEAN SWAN II DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5498	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	030704	OTHER	OK	TRICARE CONCORDIA
2	2305498	OTHER	OK	DELTA

General Provider Information

NPI Number	:	1053306985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JIMMY DEAN SWAN II DDS

Provider Business Mailing Address
First Line	:	6401 NW EXPRESSWAY
Second Line	:	SUITE 132
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73132-5170
Country	:	US
Telephone Number	:	405-728-2828
Fax Number	:	405-720-2929

Provider Business Practice Location Address
First Line	:	6401 NW EXPRESSWAY
Second Line	:	SUITE 132
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73132-5170
Country	:	US
Telephone Number	:	405-728-2828
Fax Number	:	405-720-2929

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	07/08/2007

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