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Organization
IDAHO FACIAL IMAGING LLC
Active
Organization
IDAHO FACIAL IMAGING LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BRADEN M STAUTS DDS (OWNER/PARTNER)
(208) 514-4740
Entity
Organization
Contact information
Practice address
8119 USTICK RD, SUITE 101, BOISE, ID 83704-5754
(208) 514-4740
(208) 376-7012
Mailing address
8119 USTICK RD, SUITE 101, BOISE, ID 83704-5754
(208) 514-4740
(208) 376-7012
Taxonomy
Speciality
Code
Description
License number
State
261QR0200X
Radiology Clinic/Center
Primary
4-D-2095
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010156827
REGENCE BLUE SHIELD-DENTA
ID
01
—
000010156829
REGENCE BLUE SHIELD-MEDIC
ID
Enumeration date
07/19/2006
Last updated
08/22/2020
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