Provider Demographics
NPI:1346623600
Name:SMILES IN BLOOM PEDIATRIC DENTSITRY
Entity Type:Organization
Organization Name:SMILES IN BLOOM PEDIATRIC DENTSITRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-254-5840
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:860-254-5830
Practice Address - Street 1:137 PROSPECT HILL RD
Practice Address - Street 2:
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:860-254-5830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0102281223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty