Provider Demographics
NPI:1053486845
Name:DAHL, ELLEN
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:DAHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9101
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-9494
Mailing Address - Country:US
Mailing Address - Phone:972-745-7500
Mailing Address - Fax:972-745-4336
Practice Address - Street 1:1661 EASTCHASE PKWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76120-4407
Practice Address - Country:US
Practice Address - Phone:817-459-2005
Practice Address - Fax:817-459-3797
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine