Provider Demographics
NPI:1477863678
Name:BLOOMFIELD ORAL HEALTH
Entity Type:Organization
Organization Name:BLOOMFIELD ORAL HEALTH
Other - Org Name:BLOOMFIELD ORAL HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNOOK
Authorized Official - Middle Name:
Authorized Official - Last Name:HWANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:585-657-6909
Mailing Address - Street 1:54 W MAIN ST
Mailing Address - Street 2:PO BOX 369
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14469
Mailing Address - Country:US
Mailing Address - Phone:585-657-6909
Mailing Address - Fax:585-657-7016
Practice Address - Street 1:54 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NY
Practice Address - Zip Code:14469
Practice Address - Country:US
Practice Address - Phone:585-657-6909
Practice Address - Fax:585-657-7016
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLOOMFIELD ORAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051500-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02676020Medicaid