Provider Demographics
NPI:1790703700
Name:BLOOM, MICHAEL DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
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 1:316 WESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:OCEAN CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08226-4039
Mailing Address - Country:US
Mailing Address - Phone:609-399-0227
Mailing Address - Fax:
Practice Address - Street 1:316 WESLEY AVE
Practice Address - Street 2:
Practice Address - City:OCEAN CITY
Practice Address - State:NJ
Practice Address - Zip Code:08226-4039
Practice Address - Country:US
Practice Address - Phone:609-399-0227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI014255001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3361101Medicaid