Provider Demographics
NPI:1083873939
Name:CHERILEE C BLOOM DDS PLLC
Entity Type:Organization
Organization Name:CHERILEE C BLOOM DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHERI
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-762-2544
Mailing Address - Street 1:815 W CANFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-9765
Mailing Address - Country:US
Mailing Address - Phone:108-762-2544
Mailing Address - Fax:208-762-9563
Practice Address - Street 1:815 W CANFIELD AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-9765
Practice Address - Country:US
Practice Address - Phone:108-762-2544
Practice Address - Fax:208-762-9563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3510122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty