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General NPI Number Information
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NPI Number | 1588086946
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Entity Type | Organization
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Legal Business Name | SWAN DENTAL P.C.
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Dates
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Enumeration Date | 01/19/2014
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Last Update Date | 01/19/2014
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Provider Practice Location Address
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Address Line | 23 W ROLLINS RD
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City | ROUND LAKE BEACH
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State | IL
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Zip | 60073-1350
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Country | US
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Telephone | 847-740-4600
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Fax |
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Provider Business Mailing Address
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Address Line | 1460 S PEORIA ST
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City | CHICAGO
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State | IL
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Zip | 60608-2208
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Country | US
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Telephone | 352-872-8066
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Fax |
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Authorized Official
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Title or Position | SECRETARY
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Name | SIDDHARTH BANSAL
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Credential | DMD
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Telephone | 352-872-8066
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019028736
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License Number State | IL
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