Provider Demographics
NPI:1578975397
Name:EGBERT, DANIEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:EGBERT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-461-7149
Mailing Address - Fax:208-467-3391
Practice Address - Street 1:11136 MOSS LN
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-8015
Practice Address - Country:US
Practice Address - Phone:208-466-0515
Practice Address - Fax:208-466-5359
Is Sole Proprietor?:No
Enumeration Date:2014-05-28
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6713122300000X
IDD4606122300000X
UT90837729922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1578975397Medicaid