Provider Demographics
NPI:1629416151
Name:BIRD, JAYSON ANDERS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAYSON
Middle Name:ANDERS
Last Name:BIRD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 W CAMERON AVE
Mailing Address - Street 2:
Mailing Address - City:KELLOGG
Mailing Address - State:ID
Mailing Address - Zip Code:83837-2111
Mailing Address - Country:US
Mailing Address - Phone:208-682-4540
Mailing Address - Fax:208-783-6011
Practice Address - Street 1:8 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:ID
Practice Address - Zip Code:83850
Practice Address - Country:US
Practice Address - Phone:208-680-5144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4491122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist