Provider Demographics
NPI:1972542173
Name:DAHLEN, RICHARD THOMAS (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:THOMAS
Last Name:DAHLEN
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 1:1800 CREEKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-9065
Mailing Address - Country:US
Mailing Address - Phone:406-542-3316
Mailing Address - Fax:
Practice Address - Street 1:2419 MULLAN RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808
Practice Address - Country:US
Practice Address - Phone:406-721-4906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT105142085N0700X, 2085R0202X
WAMD607053522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1041751Medicaid
MT1972542173OtherNPI