Provider Demographics
NPI:1922058866
Name:DAHLMAN, BRUCE MARK (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:MARK
Last Name:DAHLMAN
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 1:420 VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-2179
Mailing Address - Country:US
Mailing Address - Phone:218-628-1751
Mailing Address - Fax:
Practice Address - Street 1:20 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1614
Practice Address - Country:US
Practice Address - Phone:218-546-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27317207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN870867300Medicaid
D48479Medicare UPIN