Provider Demographics
NPI:1457422669
Name:LARRY D. BLOOM, DDS, PA
Entity Type:Organization
Organization Name:LARRY D. BLOOM, DDS, PA
Other - Org Name:COCHISE CHILDREN'S DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-458-1835
Mailing Address - Street 1:2273 E WILCOX DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2755
Mailing Address - Country:US
Mailing Address - Phone:520-458-1835
Mailing Address - Fax:520-459-4145
Practice Address - Street 1:2273 E WILCOX DR
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2755
Practice Address - Country:US
Practice Address - Phone:520-458-1835
Practice Address - Fax:520-459-4145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD38071223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty