Provider Demographics
NPI:1922456482
Name:BLOOMINGTON DENTAL PC
Entity Type:Organization
Organization Name:BLOOMINGTON DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:NEILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-674-9977
Mailing Address - Street 1:169 W 2710 SOUTH CIR
Mailing Address - Street 2:STE 102
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7201
Mailing Address - Country:US
Mailing Address - Phone:435-674-9977
Mailing Address - Fax:
Practice Address - Street 1:169 W 2710 SOUTH CIR
Practice Address - Street 2:STE 102
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7201
Practice Address - Country:US
Practice Address - Phone:435-674-9977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty