Provider Demographics
NPI:1518946169
Name:BIRD, JASON L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:L
Last Name:BIRD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1401 AIRPORT PKWY
Mailing Address - Street 2:140
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1518
Mailing Address - Country:US
Mailing Address - Phone:307-637-8090
Mailing Address - Fax:307-772-3327
Practice Address - Street 1:1401 AIRPORT PKWY
Practice Address - Street 2:140
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1518
Practice Address - Country:US
Practice Address - Phone:307-637-8090
Practice Address - Fax:307-772-3327
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9991223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1217704Medicaid