Provider Demographics
NPI:1023026630
Name:BIRD, DANIEL L (DDS, PA)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:L
Last Name:BIRD
Suffix:
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S AVALON ST
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4172
Mailing Address - Country:US
Mailing Address - Phone:870-732-2275
Mailing Address - Fax:870-732-1350
Practice Address - Street 1:203 S AVALON ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4172
Practice Address - Country:US
Practice Address - Phone:870-732-2275
Practice Address - Fax:870-732-1350
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1136924271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X437OtherBCBSAR
TN4072662OtherBCBS-TN ID #