Provider Demographics
NPI:1184910994
Name:BLOOM, JAMES MATTHEW (DDS)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MATTHEW
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 1:11949 LIONESS WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-6083
Mailing Address - Country:US
Mailing Address - Phone:443-804-1967
Mailing Address - Fax:
Practice Address - Street 1:11949 LIONESS WAY STE 100
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-6083
Practice Address - Country:US
Practice Address - Phone:443-804-1967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHAD341223G0001X
CODEN.002035561223X0400X
UT801366899211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004058400Medicaid