Provider Demographics
NPI:1316951239
Name:BAHNER, DALE (OD)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:BAHNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:C
Other - Middle Name:DALE
Other - Last Name:BAHNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68026-0072
Mailing Address - Country:US
Mailing Address - Phone:402-727-9220
Mailing Address - Fax:402-727-5625
Practice Address - Street 1:1445 N BELL ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-3534
Practice Address - Country:US
Practice Address - Phone:402-727-9220
Practice Address - Fax:402-727-5625
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE786152W00000X
IA01551152W00000X
MO002182152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T77025Medicare UPIN
NE096434Medicare PIN