Provider Demographics
NPI:1578061925
Name:BLOOM PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:BLOOM PEDIATRIC DENTISTRY, PLLC
Other - Org Name:BLOOM PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRIC DENTIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANELLE
Authorized Official - Middle Name:UNHAE
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:480-867-7355
Mailing Address - Street 1:1900 W GERMANN RD STE 3
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-6838
Mailing Address - Country:US
Mailing Address - Phone:480-867-7355
Mailing Address - Fax:480-907-1888
Practice Address - Street 1:1900 W GERMANN RD STE 3
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286-6838
Practice Address - Country:US
Practice Address - Phone:480-867-7355
Practice Address - Fax:480-907-1888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0094851223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ154524Medicaid