Provider Demographics
NPI:1336457837
Name:GRAND TETON DENTAL CARE
Entity Type:Organization
Organization Name:GRAND TETON DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELMER
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:CHERRY
Authorized Official - Suffix:IV
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-787-2323
Mailing Address - Street 1:741 SOUTH 50 WEST
Mailing Address - Street 2:SUITE A
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455
Mailing Address - Country:US
Mailing Address - Phone:208-787-2323
Mailing Address - Fax:208-787-2464
Practice Address - Street 1:741 SOUTH 50 WEST
Practice Address - Street 2:SUITE A
Practice Address - City:VICTOR
Practice Address - State:ID
Practice Address - Zip Code:83455
Practice Address - Country:US
Practice Address - Phone:208-787-2323
Practice Address - Fax:208-787-2464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4235261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental