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General NPI Number Information
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NPI Number | 1508378647
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Entity Type | Organization
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Legal Business Name | BIRD FAMILY DENTAL IDAHO FALLS, PLLC
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Dates
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Enumeration Date | 10/30/2017
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Last Update Date | 10/30/2017
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Provider Practice Location Address
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Address Line | 2960 CORTEZ AVE
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7554
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Country | US
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Telephone | 208-680-5144
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Fax | 208-680-5144
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Provider Business Mailing Address
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Address Line | 1392 N 800 E
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City | SHELLEY
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State | ID
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Zip | 83274-5013
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | JAYSON ANDERS BIRD
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Credential | DDS
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Telephone | 208-680-5144
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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