Basic Information
| Provider Information | |||||||||
| NPI: | 1932134202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAHL | ||||||||
| FirstName: | REYNOLD | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 INDUSTRIAL RD | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | MILFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017573588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084731480 | ||||||||
| FaxNumber: | 5084731210 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | NORTHBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015341415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5082346311 | ||||||||
| FaxNumber: | 5086344215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 12/12/2014 | ||||||||
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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 | 207Q00000X | 54988 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | J04872 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 3001130 | 05 | MA | MEDICAID |