Provider Demographics
NPI:1053460121
Name:FOSDAHL, DAVID THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:THOMAS
Last Name:FOSDAHL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20600 LAKE CHABOT RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546
Mailing Address - Country:US
Mailing Address - Phone:510-582-8399
Mailing Address - Fax:510-582-3564
Practice Address - Street 1:20600 LAKE CHABOT RD
Practice Address - Street 2:SUITE 101
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546
Practice Address - Country:US
Practice Address - Phone:510-582-8399
Practice Address - Fax:510-582-3564
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA031783122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist