Provider Demographics
NPI:1376555292
Name:CHANNING WAY DENTAL CARE
Entity Type:Organization
Organization Name:CHANNING WAY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLADE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-529-3660
Mailing Address - Street 1:2205 CHANNING WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8016
Mailing Address - Country:US
Mailing Address - Phone:208-529-3660
Mailing Address - Fax:208-529-3666
Practice Address - Street 1:2205 CHANNING WAY
Practice Address - Street 2:SUITE B
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8016
Practice Address - Country:US
Practice Address - Phone:208-529-3660
Practice Address - Fax:208-529-3666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty