=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073844296
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICHARD C SWANSON,DMD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2010
-----------------------------------------------------
Last Update Date | 01/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1815 SE HWY 19
-----------------------------------------------------
City | CRYSTAL RIVER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-795-1223
-----------------------------------------------------
Fax | 352-795-1637
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 68
-----------------------------------------------------
City | CRYSTAL RIVER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34423-0068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-795-1223
-----------------------------------------------------
Fax | 352-795-1637
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RICHARD C SWANSON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 352-795-1223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------