Provider Demographics
NPI:1679342042
Name:BLOOM ENDO, LLC
Entity Type:Organization
Organization Name:BLOOM ENDO, LLC
Other - Org Name:BLOOM ENDODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENDODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:CURTIS
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:843-647-6052
Mailing Address - Street 1:617 MYERS RD STE B
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-8902
Mailing Address - Country:US
Mailing Address - Phone:843-647-6052
Mailing Address - Fax:
Practice Address - Street 1:617 MYERS RD STE B
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-8902
Practice Address - Country:US
Practice Address - Phone:843-647-6052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-27
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty