Provider Demographics
NPI:1902026834
Name:BLOOMQUIST, MELANY K (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELANY
Middle Name:K
Last Name:BLOOMQUIST
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1590 WOODRIDGE DR SE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3818
Mailing Address - Country:US
Mailing Address - Phone:360-871-5100
Mailing Address - Fax:360-871-5104
Practice Address - Street 1:1590 WOODRIDGE DR SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3818
Practice Address - Country:US
Practice Address - Phone:360-871-5100
Practice Address - Fax:360-871-5104
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA73141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA57314OtherWASHINGTON DENTAL SERVICE
WA5018981Medicaid
WA792442OtherUNITED CONCORDIA