Provider Demographics
NPI:1043441371
Name:EGERDAHL, DAVE EARL (RD)
Entity Type:Individual
Prefix:MR
First Name:DAVE
Middle Name:EARL
Last Name:EGERDAHL
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 BRIDGE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-4274
Mailing Address - Country:US
Mailing Address - Phone:719-371-8161
Mailing Address - Fax:
Practice Address - Street 1:1338 PHAY AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2302
Practice Address - Country:US
Practice Address - Phone:719-285-2025
Practice Address - Fax:719-285-2277
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered