Provider Demographics
NPI:1932963295
Name:SHACKLEY, BRIANA AMBER (RDH)
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:AMBER
Last Name:SHACKLEY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12671 W ENDSLEY LN
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-1019
Mailing Address - Country:US
Mailing Address - Phone:208-608-6329
Mailing Address - Fax:
Practice Address - Street 1:1020 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-2776
Practice Address - Country:US
Practice Address - Phone:208-365-5064
Practice Address - Fax:208-865-1659
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDH-4447124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist