Healthcare Provider Details

I. General information

NPI: 1245275676
Provider Name (Legal Business Name): RIVERSIDE FAMILY DENTISTRY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4460 F 41
OSCODA MI
48750-9603
US

IV. Provider business mailing address

4460 F 41
OSCODA MI
48750-9603
US

V. Phone/Fax

Practice location:
  • Phone: 989-739-5255
  • Fax: 989-739-1662
Mailing address:
  • Phone: 989-739-5255
  • Fax: 989-739-1662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901017272
License Number StateMI

VIII. Authorized Official

Name: DR. TARA ELANN SWANTON
Title or Position: CEO DENTIST OWNER
Credential: D.D.S.
Phone: 989-739-5255