Provider Demographics
NPI:1255466843
Name:BLOOM, MATTHEW IRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:IRA
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 WAVERLY PL
Mailing Address - Street 2:1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-9147
Mailing Address - Country:US
Mailing Address - Phone:212-460-0955
Mailing Address - Fax:212-460-0956
Practice Address - Street 1:123 WAVERLY PL
Practice Address - Street 2:1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-9147
Practice Address - Country:US
Practice Address - Phone:212-460-0955
Practice Address - Fax:212-460-0956
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY0317781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice