Provider Demographics
NPI:1588786875
Name:CHANNING WAY DENTAL DBA LOST RIVERS DENTAL
Entity type:Organization
Organization Name:CHANNING WAY DENTAL DBA LOST RIVERS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTENSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-527-3472
Mailing Address - Street 1:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:ARCO
Mailing Address - State:ID
Mailing Address - Zip Code:83213-0005
Mailing Address - Country:US
Mailing Address - Phone:208-527-3472
Mailing Address - Fax:208-527-8955
Practice Address - Street 1:520 HIGHLAND DRIVE
Practice Address - Street 2:
Practice Address - City:ARCO
Practice Address - State:ID
Practice Address - Zip Code:83213
Practice Address - Country:US
Practice Address - Phone:208-527-3472
Practice Address - Fax:208-527-8955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD37031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty