Provider Demographics
NPI:1992227672
Name:DAHLBERG, BRYAN R
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:R
Last Name:DAHLBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20910 74TH AVENUE CT E # CTE
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-5260
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14016 A ST S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-4662
Practice Address - Country:US
Practice Address - Phone:253-302-3675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist