Provider Demographics
NPI:1861015653
Name:DAN STREEBY, D.D.S.
Entity type:Organization
Organization Name:DAN STREEBY, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:STREEBY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-939-0600
Mailing Address - Street 1:450 W STATE ST STE 180
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6974
Mailing Address - Country:US
Mailing Address - Phone:208-939-0600
Mailing Address - Fax:208-939-0774
Practice Address - Street 1:450 W STATE ST STE 180
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6974
Practice Address - Country:US
Practice Address - Phone:208-939-0600
Practice Address - Fax:208-939-0774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID28911Medicaid