Healthcare Provider Details

I. General information

NPI: 1902737760
Provider Name (Legal Business Name): BENJAMIN DANIEL BIRD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 NORTHSIDE CHEROKEE BLVD
CANTON GA
30115-8015
US

IV. Provider business mailing address

355 KEELER WOODS DR NW # MW
MARIETTA GA
30064-2018
US

V. Phone/Fax

Practice location:
  • Phone: 770-545-4848
  • Fax:
Mailing address:
  • Phone: 770-545-4848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: