Provider Demographics
NPI:1235385410
Name:BLOOM, JUSTIN R (DMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:R
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 806
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06088-0806
Mailing Address - Country:US
Mailing Address - Phone:860-254-5840
Mailing Address - Fax:
Practice Address - Street 1:137 PROSPECT HILL RD
Practice Address - Street 2:SUITE C
Practice Address - City:EAST WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06088-3602
Practice Address - Country:US
Practice Address - Phone:860-254-5840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0102281223P0221X
PADS0375181223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry