Healthcare Provider Details

I. General information

NPI: 1740582477
Provider Name (Legal Business Name): MARK PHILIP SWENSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 NW LINCOLN AVE
CORVALLIS OR
97330-2503
US

IV. Provider business mailing address

2222 NW LINCOLN AVE
CORVALLIS OR
97330-2503
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-4017
  • Fax:
Mailing address:
  • Phone: 541-754-4017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD9063
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: