Provider Demographics
NPI:1376257881
Name:BOMM, NATHAN LUCAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:LUCAS
Last Name:BOMM
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 1:2813 4TH ST SE UNIT 620
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3013
Mailing Address - Country:US
Mailing Address - Phone:262-225-7291
Mailing Address - Fax:
Practice Address - Street 1:3405 PROMENADE AVE STE 300
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-4420
Practice Address - Country:US
Practice Address - Phone:651-236-7458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14815122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND14815OtherSTATE OF MINNESOTA BOARD OF DENTISTRY