Provider Demographics
NPI:1134567852
Name:BRIAN BIRD DMD, PLLC
Entity type:Organization
Organization Name:BRIAN BIRD DMD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-869-1038
Mailing Address - Street 1:1744 N MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-6542
Mailing Address - Country:US
Mailing Address - Phone:208-322-1263
Mailing Address - Fax:
Practice Address - Street 1:1744 N MITCHELL ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-6542
Practice Address - Country:US
Practice Address - Phone:208-322-1263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-05
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3837122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID7464020001Medicare NSC