Basic Information
| Provider Information | |||||||||
| NPI: | 1407061997 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAHL | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 13865 POMEGANATE DR | ||||||||
| Address2: | |||||||||
| City: | FRISCO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202267749 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11650 US HIGHWAY 380 STE 100 | ||||||||
| Address2: | |||||||||
| City: | CROSSROADS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762278329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9402054293 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 33992 | TX | N | Dental Providers | Dentist | General Practice | 1223G0001X | D7219 | AZ | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 33992 | 01 | TX | TEXAS DENTAL LICENSE | OTHER |