Healthcare Provider Details

I. General information

NPI: 1548291354
Provider Name (Legal Business Name): FREDERICK J DAHL R.R.A. (ARRT)(R) RPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S GLOSTER ST
TUPELO MS
38801-4996
US

IV. Provider business mailing address

111 JEAN JANE LN
TUPELO MS
38804-9113
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-5232
  • Fax:
Mailing address:
  • Phone: 603-661-5485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471V0106X
TaxonomyVascular-Interventional Technology Radiologic Technologist
License Number09125
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number09125
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License NumberRA00005
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: