Provider Demographics
NPI:1467527143
Name:BLOOM, ROBERT JAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JAY
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:393 N DUNLAP ST
Mailing Address - Street 2:SUITE 100 CENTRAL MEDICAL BLDG
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:651-646-1318
Mailing Address - Fax:651-642-2592
Practice Address - Street 1:393 N DUNLAP ST
Practice Address - Street 2:SUITE 100 CENTRAL MEDICAL BLDG
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-646-1318
Practice Address - Fax:651-642-2592
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN80221223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics