Provider Demographics
NPI:1003831223
Name:EGBERT, DAN (DC)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:
Last Name:EGBERT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1273 W 12600 S STE 401
Mailing Address - Street 2:P.O. BOX 949
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7111
Mailing Address - Country:US
Mailing Address - Phone:801-446-0383
Mailing Address - Fax:801-446-0391
Practice Address - Street 1:1273 W 12600 S STE 401
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7111
Practice Address - Country:US
Practice Address - Phone:801-446-0383
Practice Address - Fax:801-446-0391
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT292680-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870395551005Medicaid
UTU31603Medicare UPIN
UT000056152Medicare ID - Type Unspecified