Provider Demographics
NPI:1992143978
Name:BIRD FAMILY DENTAL, PLLC
Entity type:Organization
Organization Name:BIRD FAMILY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYSON
Authorized Official - Middle Name:ANDERS
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-680-5144
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:ID
Mailing Address - Zip Code:83850-0609
Mailing Address - Country:US
Mailing Address - Phone:208-682-4540
Mailing Address - Fax:
Practice Address - Street 1:8 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:ID
Practice Address - Zip Code:83850
Practice Address - Country:US
Practice Address - Phone:208-682-4540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4491261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental