Provider Demographics
NPI:1316931819
Name:BIRD, BRIAN (DMD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BIRD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1744 N MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-6542
Mailing Address - Country:US
Mailing Address - Phone:208-869-1038
Mailing Address - Fax:
Practice Address - Street 1:1744 N MITCHELL ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-6542
Practice Address - Country:US
Practice Address - Phone:208-869-1038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3837122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist