Healthcare Provider Details

I. General information

NPI: 1033197108
Provider Name (Legal Business Name): JAMES WILLIAM SWENSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36839 DEER TRAIL DR
LAKE VILLA IL
60046-6734
US

IV. Provider business mailing address

36839 DEER TRAIL DR
LAKE VILLA IL
60046-6734
US

V. Phone/Fax

Practice location:
  • Phone: 847-265-1956
  • Fax:
Mailing address:
  • Phone: 847-265-1956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number5575-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: