Provider Demographics
NPI:1104189430
Name:BLOOMING DENTAL PLLC
Entity Type:Organization
Organization Name:BLOOMING DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCIAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:646-861-2404
Mailing Address - Street 1:16411 CROCHERON AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-2015
Mailing Address - Country:US
Mailing Address - Phone:646-861-2404
Mailing Address - Fax:
Practice Address - Street 1:150 E 58TH ST
Practice Address - Street 2:8TH FLOOR ANNEX
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10155-0002
Practice Address - Country:US
Practice Address - Phone:646-861-2404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047318122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty