Provider Demographics
NPI:1477616928
Name:DAHLGREN, STEPHEN GLENN (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:GLENN
Last Name:DAHLGREN
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 1:5086 MILLER TRUNK HWY
Mailing Address - Street 2:
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-1490
Mailing Address - Country:US
Mailing Address - Phone:218-729-9810
Mailing Address - Fax:218-729-9812
Practice Address - Street 1:5086 MILLER TRUNK HWY
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-1490
Practice Address - Country:US
Practice Address - Phone:218-729-9810
Practice Address - Fax:218-729-9812
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8279122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN74450DAOtherBLUECROSS BLUESHIELD