Healthcare Provider Details

I. General information

NPI: 1790155430
Provider Name (Legal Business Name): BYRD DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 10/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 E CAMERON AVE
KELLOGG ID
83837-2333
US

IV. Provider business mailing address

302 E CAMERON AVE
KELLOGG ID
83837-2333
US

V. Phone/Fax

Practice location:
  • Phone: 208-786-7031
  • Fax:
Mailing address:
  • Phone: 208-786-7031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD-4696
License Number StateID

VIII. Authorized Official

Name: BENJAMIN LUKE BYRD
Title or Position: OWNER
Credential: D.D.S.
Phone: 208-786-7031