Provider Demographics
NPI:1588010565
Name:BLOOMING DENTAL PLLC
Entity Type:Organization
Organization Name:BLOOMING DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-250-2356
Mailing Address - Street 1:111 N VISTA RIDGE BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-0000
Mailing Address - Country:US
Mailing Address - Phone:512-250-2356
Mailing Address - Fax:
Practice Address - Street 1:111 N VISTA RIDGE BLVD
Practice Address - Street 2:STE 100
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-0000
Practice Address - Country:US
Practice Address - Phone:512-250-2356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX190391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty