Provider Demographics
NPI:1326135260
Name:BLOMBERG, OLOF LOWRY (DMD)
Entity Type:Individual
Prefix:
First Name:OLOF
Middle Name:LOWRY
Last Name:BLOMBERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:OLE
Other - Middle Name:
Other - Last Name:BLOMBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:114 SEVEN SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:MT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-3859
Mailing Address - Country:US
Mailing Address - Phone:615-301-1614
Mailing Address - Fax:615-889-2989
Practice Address - Street 1:3515 CENTRAL PIKE
Practice Address - Street 2:SUITE 202
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-2029
Practice Address - Country:US
Practice Address - Phone:615-889-4658
Practice Address - Fax:615-889-2989
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8452122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ027151Medicaid