Provider Demographics
NPI:1467716167
Name:BLOOM, LARRY DEAN (DDS)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DEAN
Last Name:BLOOM
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 1:131 CARMICHAEL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-8271
Mailing Address - Country:US
Mailing Address - Phone:855-527-3848
Mailing Address - Fax:
Practice Address - Street 1:131 CARMICHAEL RD STE 200
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8271
Practice Address - Country:US
Practice Address - Phone:855-527-3848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6844-151223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry