Provider Demographics
NPI:1497563480
Name:DAHL, JAIME
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:DAHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:656 SPARKES RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-5043
Mailing Address - Country:US
Mailing Address - Phone:707-484-9339
Mailing Address - Fax:
Practice Address - Street 1:16387 FIRST ST FL 3
Practice Address - Street 2:
Practice Address - City:GUERNEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95446-8817
Practice Address - Country:US
Practice Address - Phone:707-869-2933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-21
Last Update Date:2024-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23924124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist