Provider Demographics
NPI:1760454938
Name:DAHLE, MICHAEL G (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:DAHLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MARGARET LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5211
Mailing Address - Country:US
Mailing Address - Phone:530-272-9058
Mailing Address - Fax:530-272-3324
Practice Address - Street 1:105 MARGARET LN
Practice Address - Street 2:SUITE B
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5211
Practice Address - Country:US
Practice Address - Phone:530-272-9058
Practice Address - Fax:530-272-3324
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G411110Medicaid
CA00G411110Medicaid
00G411110Medicare PIN