Provider Demographics
NPI:1689750705
Name:NIEBLOOM, THEODORE A (DMD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:A
Last Name:NIEBLOOM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 OLD SHORT HILLS ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052
Mailing Address - Country:US
Mailing Address - Phone:973-736-7616
Mailing Address - Fax:973-325-3487
Practice Address - Street 1:101 OLD SHORT HILLS ROAD
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052
Practice Address - Country:US
Practice Address - Phone:973-736-7616
Practice Address - Fax:973-325-3487
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI016042001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU29981Medicare UPIN
NJ138026Medicare PIN