# FAMLIY DENTAL HEALTH CENTER

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Burtenshaw Craig A & G Staley GPS
- **Organization subpart:** No

## Provider details

- **NPI number:** 1679745269
- **Authorized official:** DR. GALEN JAY STALEY DDS (PARTNER)
- **Authorized official phone:** (208) 529-0120

## Contact information

- **Practice address:** 200 N WOODRUFF AVE, IDAHO FALLS, ID 83401-4334
- **Practice address phone:** (208) 529-0120
- **Mailing address:** 200 N WOODRUFF AVE, IDAHO FALLS, ID 83401-4334
- **Mailing address phone:** (208) 529-0120

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | D1628 | ID | — |
| 122300000X | Dentist | D3038 | ID | — |
| 122300000X | Dentist | D3064 | ID | Yes |
| 122300000X | Dentist | D3614 | ID | — |

## Other

- **Enumeration date:** 03/24/2008
- **Last updated:** 06/19/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 00274600 | — | ID |
| 05 | — | 02740700 | — | ID |
| 05 | — | 806335900 | — | ID |
| 05 | — | 806939100 | — | ID |