Healthcare Provider Details

I. General information

NPI: 1922786714
Provider Name (Legal Business Name): DYLAN DAGENBACK PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 CHAMBLEE DUNWOODY RD STE 5B
DUNWOODY GA
30338-4162
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
HOOVER AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 770-396-3003
  • Fax:
Mailing address:
  • Phone: 866-518-0283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT020540
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: