Provider Demographics
NPI:1275663791
Name:NYDEGGER, DAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:
Last Name:NYDEGGER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15661 W ROOSEVELT PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-9307
Mailing Address - Country:US
Mailing Address - Phone:623-882-1400
Mailing Address - Fax:623-882-1300
Practice Address - Street 1:15661 W ROOSEVELT PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-9307
Practice Address - Country:US
Practice Address - Phone:623-882-1400
Practice Address - Fax:623-882-1300
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5540122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ619645OtherAHCCCS