Provider Demographics
NPI:1508378647
Name:BIRD FAMILY DENTAL IDAHO FALLS, PLLC
Entity Type:Organization
Organization Name:BIRD FAMILY DENTAL IDAHO FALLS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAYSON
Authorized Official - Middle Name:ANDERS
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-680-5144
Mailing Address - Street 1:1392 N 800 E
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-5013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2960 CORTEZ AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7554
Practice Address - Country:US
Practice Address - Phone:208-680-5144
Practice Address - Fax:208-680-5144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental