Provider Demographics
NPI:1033554845
Name:MICHAEL A. BLOOM D.M.D. PLLC
Entity Type:Organization
Organization Name:MICHAEL A. BLOOM D.M.D. PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-772-3583
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:HAYDEN LAKE
Mailing Address - State:ID
Mailing Address - Zip Code:83835-0425
Mailing Address - Country:US
Mailing Address - Phone:208-772-3583
Mailing Address - Fax:208-772-3224
Practice Address - Street 1:9928 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:HAYDEN LAKE
Practice Address - State:ID
Practice Address - Zip Code:83835-9604
Practice Address - Country:US
Practice Address - Phone:208-772-3583
Practice Address - Fax:208-772-3224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3394302R00000X
IDD3555302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization