Healthcare Provider Details

I. General information

NPI: 1164618344
Provider Name (Legal Business Name): KATHRYN ANNE SWAN D.D.S., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 06/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6677 CROSSINGS DR SE SUITE 2
GRAND RAPIDS MI
49508-7889
US

IV. Provider business mailing address

6677 CROSSINGS DR SE SUITE 2
GRAND RAPIDS MI
49508-7889
US

V. Phone/Fax

Practice location:
  • Phone: 616-698-2323
  • Fax: 616-871-9253
Mailing address:
  • Phone: 616-698-2323
  • Fax: 616-871-9253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901019044
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: