Provider Demographics
NPI:1578588364
Name:STAUTS, BRADEN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADEN
Middle Name:M
Last Name:STAUTS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N CURTIS RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1337
Mailing Address - Country:US
Mailing Address - Phone:208-376-0567
Mailing Address - Fax:208-376-0661
Practice Address - Street 1:1000 N CURTIS RD
Practice Address - Street 2:SUITE 203
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1337
Practice Address - Country:US
Practice Address - Phone:208-376-0567
Practice Address - Fax:208-376-0661
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-2083-PR1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID45353Medicare UPIN
ID1204123Medicare ID - Type Unspecified