Provider Demographics
NPI:1326046301
Name:BLOOM, RICHARD MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MICHAEL
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 1:2870 HEMPSTEAD TPKE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-1341
Mailing Address - Country:US
Mailing Address - Phone:516-579-7744
Mailing Address - Fax:
Practice Address - Street 1:2870 HEMPSTEAD TPKE
Practice Address - Street 2:SUITE 101
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-1341
Practice Address - Country:US
Practice Address - Phone:516-579-7744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
NY0345311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice