Healthcare Provider Details

I. General information

NPI: 1841763513
Provider Name (Legal Business Name): SWAN PEDIATRIC DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2019
Last Update Date: 01/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N STATE ROAD 198
SALEM UT
84653-4504
US

IV. Provider business mailing address

1177 W 1960 N
PLEASANT GROVE UT
84062-4039
US

V. Phone/Fax

Practice location:
  • Phone: 801-423-7969
  • Fax:
Mailing address:
  • Phone: 801-718-8348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW ALLEN SWAN
Title or Position: OWNER
Credential: DDS
Phone: 801-718-8348