Provider Demographics
NPI:1841805991
Name:BLOOM PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:BLOOM PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-666-6091
Mailing Address - Street 1:201 SE WASHINGTON ST STE A
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-2860
Mailing Address - Country:US
Mailing Address - Phone:503-507-0996
Mailing Address - Fax:
Practice Address - Street 1:201 SE WASHINGTON ST STE A
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-2860
Practice Address - Country:US
Practice Address - Phone:503-507-0996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-14
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty