Provider Demographics
NPI:1437178399
Name:IDAHO FACIAL IMAGING LLC
Entity type:Organization
Organization Name:IDAHO FACIAL IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:STAUTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-514-4740
Mailing Address - Street 1:8119 USTICK RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5754
Mailing Address - Country:US
Mailing Address - Phone:208-514-4740
Mailing Address - Fax:208-376-7012
Practice Address - Street 1:8119 USTICK RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5754
Practice Address - Country:US
Practice Address - Phone:208-514-4740
Practice Address - Fax:208-376-7012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4-D-2095261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010156829OtherREGENCE BLUE SHIELD-MEDIC
ID000010156827OtherREGENCE BLUE SHIELD-DENTA