Provider Demographics
NPI:1821188095
Name:TOMMERVIK, DALE ARTHUR (PT)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:ARTHUR
Last Name:TOMMERVIK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 475
Mailing Address - Street 2:BOX 375
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USAHC-SFT
Practice Address - Street 2:CMR 457
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09033
Practice Address - Country:US
Practice Address - Phone:49972-196-6561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00000836171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider