Provider Demographics
NPI:1194398776
Name:DAHL, ETHAN DENNIS
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:DENNIS
Last Name:DAHL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:INGLESIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60041-8324
Mailing Address - Country:US
Mailing Address - Phone:847-587-3312
Mailing Address - Fax:
Practice Address - Street 1:306 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:INGLESIDE
Practice Address - State:IL
Practice Address - Zip Code:60041-8324
Practice Address - Country:US
Practice Address - Phone:847-587-3312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060783107146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic