Provider Demographics
NPI:1205981511
Name:DAHLSTROM, GARY (DO)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:DAHLSTROM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 LANCASTER DR NE STE 103
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1040
Mailing Address - Country:US
Mailing Address - Phone:503-585-4131
Mailing Address - Fax:
Practice Address - Street 1:1880 LANCASTER DR NE STE 103
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1040
Practice Address - Country:US
Practice Address - Phone:503-585-4131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR271734111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor