Healthcare Provider Details

I. General information

NPI: 1437714805
Provider Name (Legal Business Name): BRANDON ALLEN DYRDAHL DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 MID VALLEY DR STE C
DE PERE WI
54115-9517
US

IV. Provider business mailing address

1680 MID VALLEY DR STE C
DE PERE WI
54115-9517
US

V. Phone/Fax

Practice location:
  • Phone: 920-658-5040
  • Fax: 920-658-5039
Mailing address:
  • Phone: 920-658-5040
  • Fax: 920-658-5039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5470-12
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: