Provider Demographics
NPI:1245430057
Name:BLOOM, SPENCER ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:ROBERT
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 1:5530 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1330
Mailing Address - Country:US
Mailing Address - Phone:773-777-3309
Mailing Address - Fax:773-777-3856
Practice Address - Street 1:5530 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-1330
Practice Address - Country:US
Practice Address - Phone:773-777-3309
Practice Address - Fax:773-777-3856
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice