Provider Demographics
NPI:1699770461
Name:DAHLIN, KENNETH CHARLES (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CHARLES
Last Name:DAHLIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4502 S STEELE ST
Mailing Address - Street 2:STE 304B
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7258
Mailing Address - Country:US
Mailing Address - Phone:253-475-3937
Mailing Address - Fax:253-473-4278
Practice Address - Street 1:4502 S STEELE ST
Practice Address - Street 2:STE 304B
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7242
Practice Address - Country:US
Practice Address - Phone:253-475-3937
Practice Address - Fax:253-473-4278
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001353152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2029411Medicaid
WA2029411Medicaid