Provider Demographics
NPI:1043320179
Name:BLOOM, CHERILEE C (DDS)
Entity Type:Individual
Prefix:
First Name:CHERILEE
Middle Name:C
Last Name:BLOOM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 WEST CANFIELD AVENUE
Mailing Address - Street 2:
Mailing Address - City:COEUR DALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815
Mailing Address - Country:US
Mailing Address - Phone:208-762-2544
Mailing Address - Fax:208-762-9563
Practice Address - Street 1:815 WEST CANFIELD AVENUE
Practice Address - Street 2:
Practice Address - City:COEUR DALENE
Practice Address - State:ID
Practice Address - Zip Code:83815
Practice Address - Country:US
Practice Address - Phone:208-762-2544
Practice Address - Fax:208-762-9563
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD35101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice