Provider Demographics
NPI:1013067859
Name:BIRD, GERALD WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:WILLIAM
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 1:96 WILLARD ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7991
Mailing Address - Country:US
Mailing Address - Phone:321-631-7000
Mailing Address - Fax:321-631-5135
Practice Address - Street 1:96 WILLARD ST
Practice Address - Street 2:SUITE 105
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7991
Practice Address - Country:US
Practice Address - Phone:321-631-7000
Practice Address - Fax:321-631-5135
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL102511223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL60914Medicare ID - Type Unspecified