Provider Demographics
NPI:1740605104
Name:STACKOWICZ, DANIEL JOHN (DDS)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOHN
Last Name:STACKOWICZ
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 1:1410 S ENTERTAINMENT AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-8306
Mailing Address - Country:US
Mailing Address - Phone:208-321-4937
Mailing Address - Fax:208-321-4834
Practice Address - Street 1:1410 S ENTERTAINMENT AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-8306
Practice Address - Country:US
Practice Address - Phone:208-321-4937
Practice Address - Fax:208-321-4834
Is Sole Proprietor?:No
Enumeration Date:2014-02-21
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDD51621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program