Provider Demographics
NPI:1457845133
Name:BLOOMER, CAITLIN (DDS)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
Last Name:BLOOMER
Suffix:
Gender:F
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:W5571 GLADWATER BEACH RD
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:WI
Mailing Address - Zip Code:53049-1113
Mailing Address - Country:US
Mailing Address - Phone:920-645-1219
Mailing Address - Fax:
Practice Address - Street 1:2011 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:NEW HOLSTEIN
Practice Address - State:WI
Practice Address - Zip Code:53061-1316
Practice Address - Country:US
Practice Address - Phone:920-645-1219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001838-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice