Provider Demographics
NPI:1851628903
Name:BLOOMINGTON FAMILY DENTAL
Entity Type:Organization
Organization Name:BLOOMINGTON FAMILY DENTAL
Other - Org Name:BLOOMINGTON FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:KLOBOVES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-824-1600
Mailing Address - Street 1:4000 S. OLD STATE RD US 37
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-7412
Mailing Address - Country:US
Mailing Address - Phone:812-824-1600
Mailing Address - Fax:812-824-1615
Practice Address - Street 1:4000 SOUTH OLD STATE RD US 37
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-7412
Practice Address - Country:US
Practice Address - Phone:812-824-1600
Practice Address - Fax:812-824-1615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010746B122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200522010Medicaid