Provider Demographics
NPI:1407803356
Name:KENNETH C. DAHLIN, O.D., PLLC
Entity Type:Organization
Organization Name:KENNETH C. DAHLIN, O.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-472-6465
Mailing Address - Street 1:4502 S STEELE ST
Mailing Address - Street 2:SUITE 304-B
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4502 S STEELE ST
Practice Address - Street 2:SUITE 304-B
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7242
Practice Address - Country:US
Practice Address - Phone:253-472-6465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1353152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8850750Medicare ID - Type Unspecified