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General NPI Number Information
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NPI Number | 1790155430
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Entity Type | Organization
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Legal Business Name | BYRD DENTISTRY, PLLC
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Dates
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Enumeration Date | 10/06/2015
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Last Update Date | 10/06/2015
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Provider Practice Location Address
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Address Line | 302 E CAMERON AVE
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City | KELLOGG
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State | ID
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Zip | 83837-2333
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Country | US
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Telephone | 208-786-7031
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Fax |
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Provider Business Mailing Address
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Address Line | 302 E CAMERON AVE
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City | KELLOGG
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State | ID
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Zip | 83837-2333
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Country | US
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Telephone | 208-786-7031
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BENJAMIN LUKE BYRD
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Credential | D.D.S.
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Telephone | 208-786-7031
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D-4696
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License Number State | ID
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