Provider Demographics
NPI:1740415520
Name:WILLIAM K DAHL
Entity Type:Organization
Organization Name:WILLIAM K DAHL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:K
Authorized Official - Last Name:DAHL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:207-945-5554
Mailing Address - Street 1:205 FRENCH ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5064
Mailing Address - Country:US
Mailing Address - Phone:207-945-5554
Mailing Address - Fax:204-945-5196
Practice Address - Street 1:205 FRENCH ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5064
Practice Address - Country:US
Practice Address - Phone:207-945-5554
Practice Address - Fax:204-945-5196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-21
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD200213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME220000000Medicaid
ME220000000Medicaid