Provider Demographics
NPI:1619096203
Name:PRIEBE, DEREK N (DDS MDS)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:N
Last Name:PRIEBE
Suffix:
Gender:M
Credentials:DDS MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 DENALI ST
Mailing Address - Street 2:203
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-4034
Mailing Address - Country:US
Mailing Address - Phone:907-563-2828
Mailing Address - Fax:907-561-0374
Practice Address - Street 1:3401 DENALI ST
Practice Address - Street 2:203
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-4034
Practice Address - Country:US
Practice Address - Phone:907-563-2828
Practice Address - Fax:907-561-0374
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1089.1311223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD1590Medicaid