Provider Demographics
NPI:1801814546
Name:DAHL, BRUCE L (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:DAHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 SHEYENNE ST
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-2637
Mailing Address - Country:US
Mailing Address - Phone:701-234-4446
Mailing Address - Fax:701-234-4455
Practice Address - Street 1:1220 SHEYENNE ST
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-2637
Practice Address - Country:US
Practice Address - Phone:701-234-4446
Practice Address - Fax:701-234-4455
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3903207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13239Medicaid
NDN716532Medicare PIN
ND13239Medicaid
D25824Medicare UPIN