Provider Demographics
NPI:1982762837
Name:BYRD, BOBBY GENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:GENE
Last Name:BYRD
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 1:130 EL CAMINO REAL
Mailing Address - Street 2:#100
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3659
Mailing Address - Country:US
Mailing Address - Phone:714-573-1111
Mailing Address - Fax:
Practice Address - Street 1:130 EL CAMINO REAL
Practice Address - Street 2:#100
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3659
Practice Address - Country:US
Practice Address - Phone:714-573-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA147331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB1473301Medicaid