| Burtenshaw Craig A & G Staley Gps | |
|
200 N Woodruff Ave Idaho Falls ID 83401-4334 | |
| (208) 529-0120 | |
| Not Available |
| Full Name | Burtenshaw Craig A & G Staley Gps |
|---|---|
| Speciality | Dentist |
| Location | 200 N Woodruff Ave, Idaho Falls, Idaho |
| Authorized Official Name and Position | Galen Jay Staley (PARTNER) |
| Authorized Official Contact | 2085290120 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Burtenshaw Craig A & G Staley Gps 200 N Woodruff Ave Idaho Falls ID 83401-4334 Ph: (208) 529-0120 | Burtenshaw Craig A & G Staley Gps 200 N Woodruff Ave Idaho Falls ID 83401-4334 Ph: (208) 529-0120 |
| NPI Number | 1679745269 |
|---|---|
| Provider Enumeration Date | 03/24/2008 |
| Last Update Date | 06/19/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1679745269 | NPI | - | NPPES |
| 806335900 | Medicaid | ID | |
| 806939100 | Medicaid | ID | |
| 02740700 | Medicaid | ID | |
| 00274600 | Medicaid | ID |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | D1628 (Idaho) | Secondary |
| 122300000X | Dentist | D3064 (Idaho) | Primary |
| 122300000X | Dentist | D3614 (Idaho) | Secondary |
| 122300000X | Dentist | D3038 (Idaho) | Secondary |
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