Provider Demographics
NPI:1104884774
Name:BIRD, SUZANNE ELIZABETH (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:ELIZABETH
Last Name:BIRD
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:SUZANNE
Other - Middle Name:BIRD
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:16607 RIVERSTONE WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277
Mailing Address - Country:US
Mailing Address - Phone:704-840-6803
Mailing Address - Fax:704-544-5003
Practice Address - Street 1:16607 RIVERSTONE WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277
Practice Address - Country:US
Practice Address - Phone:704-840-6803
Practice Address - Fax:704-544-5003
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7109122300000X, 1223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5909061Medicaid