Provider Demographics
NPI:1144392440
Name:BLOOM, JEFFREY T (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:T
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 1:631 ST ANNE ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701
Mailing Address - Country:US
Mailing Address - Phone:605-343-6003
Mailing Address - Fax:605-342-0998
Practice Address - Street 1:631 ST ANNE ST
Practice Address - Street 2:SUITE 105
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701
Practice Address - Country:US
Practice Address - Phone:605-343-6003
Practice Address - Fax:605-342-0998
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM660122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist