Provider Demographics
NPI:1659487429
Name:BLOOM, FREDERICK NEIL (DDS)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:NEIL
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 1:64 PALOMBA DR
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3844
Mailing Address - Country:US
Mailing Address - Phone:860-745-2712
Mailing Address - Fax:860-741-3109
Practice Address - Street 1:64 PALOMBA DR
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3844
Practice Address - Country:US
Practice Address - Phone:860-745-2712
Practice Address - Fax:860-741-3109
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4358122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist