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General NPI Number Information
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NPI Number | 1588786875
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Entity Type | Organization
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Legal Business Name | CHANNING WAY DENTAL DBA LOST RIVERS DENTAL
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Dates
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Enumeration Date | 04/06/2007
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Last Update Date | 03/25/2008
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Provider Practice Location Address
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Address Line | 520 HIGHLAND DRIVE
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City | ARCO
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State | ID
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Zip | 83213
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Country | US
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Telephone | 208-527-3472
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Fax | 208-527-8955
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Provider Business Mailing Address
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Address Line | PO BOX 5
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City | ARCO
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State | ID
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Zip | 83213-0005
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Country | US
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Telephone | 208-527-3472
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Fax | 208-527-8955
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Authorized Official
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Title or Position | PARTNER
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Name | DR. COREY CHRISTENSE
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Credential | D.D.S.
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Telephone | 208-527-3472
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D3703
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License Number State | ID
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