Provider Demographics
NPI:1437567823
Name:BLOOMQUIST, GEOFFREY IAN (DMD)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:IAN
Last Name:BLOOMQUIST
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 BRUSHY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-4008
Mailing Address - Country:US
Mailing Address - Phone:864-244-3131
Mailing Address - Fax:864-244-3132
Practice Address - Street 1:1405 BRUSHY CREEK RD
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-4008
Practice Address - Country:US
Practice Address - Phone:864-244-3131
Practice Address - Fax:864-244-3132
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8441122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist