Provider Demographics
NPI:1396795068
Name:STREEBY, DAN (DDS)
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:STREEBY
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 1:450 W STATE ST
Mailing Address - Street 2:STE 180
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
Practice Address - Street 2:STE 180
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:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3301PD122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDD3301PDOtherSTATE LICENSE #