=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184788614
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SWANSON FAMILY DENTRISTRY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12450 WAYZATA BLVD STE 214
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55305-1934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-545-2838
-----------------------------------------------------
Fax | 952-545-7649
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12450 WAYZATA BLVD STE 214
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55305-1934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-545-2838
-----------------------------------------------------
Fax | 952-545-7649
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES
-----------------------------------------------------
Name | JAMES TIMOTHY SWANSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 952-545-2838
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------