Provider Demographics
NPI:1093884462
Name:BLOOM, JONATHAN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:A
Last Name:BLOOM
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 1:120 NICKLAUS CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-8015
Mailing Address - Country:US
Mailing Address - Phone:802-497-0814
Mailing Address - Fax:802-497-0814
Practice Address - Street 1:118 TILLEY DR STE 101
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-4450
Practice Address - Country:US
Practice Address - Phone:802-863-3950
Practice Address - Fax:802-863-3601
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT22681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice