Provider Demographics
NPI:1679745269
Name:FAMLIY DENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:FAMLIY DENTAL HEALTH CENTER
Other - Org Name:BURTENSHAW CRAIG A & G STALEY GPS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:STALEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-529-0120
Mailing Address - Street 1:200 N WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4334
Mailing Address - Country:US
Mailing Address - Phone:208-529-0120
Mailing Address - Fax:
Practice Address - Street 1:200 N WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4334
Practice Address - Country:US
Practice Address - Phone:208-529-0120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1628122300000X
IDD3064122300000X
IDD3614122300000X
IDD3038122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806335900Medicaid
ID806939100Medicaid
ID02740700Medicaid
ID00274600Medicaid