# CHANNING WAY DENTAL CARE

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1376555292
- **Authorized official:** DR. GLADE L. PETERSON D.M.D. (OWNER/PARTNER)
- **Authorized official phone:** (208) 529-3660

## Contact information

- **Practice address:** 2205 CHANNING WAY, SUITE B, IDAHO FALLS, ID 83404-8016
- **Practice address phone:** (208) 529-3660
- **Practice address fax:** (208) 529-3666
- **Mailing address:** 2205 CHANNING WAY, SUITE B, IDAHO FALLS, ID 83404-8016
- **Mailing address phone:** (208) 529-3660
- **Mailing address fax:** (208) 529-3666

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 08/12/2006
- **Last updated:** 03/25/2008