Provider Demographics
NPI:1548323579
Name:BYRD, THOMAS RAYMOND (DMD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RAYMOND
Last Name:BYRD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 97632
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39288-7632
Mailing Address - Country:US
Mailing Address - Phone:601-845-2386
Mailing Address - Fax:601-845-1470
Practice Address - Street 1:129 EARL CLARK DR.
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073
Practice Address - Country:US
Practice Address - Phone:601-845-2386
Practice Address - Fax:601-845-1470
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660274Medicaid