Provider Demographics
NPI:1780288977
Name:MT CALVARY DENTAL LLC
Entity type:Organization
Organization Name:MT CALVARY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CAITLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-645-1219
Mailing Address - Street 1:3500 WOODVIEW LN
Mailing Address - Street 2:
Mailing Address - City:SAUKVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53080-1400
Mailing Address - Country:US
Mailing Address - Phone:920-645-1219
Mailing Address - Fax:
Practice Address - Street 1:100 EVERGREEN RD
Practice Address - Street 2:
Practice Address - City:MOUNT CALVARY
Practice Address - State:WI
Practice Address - Zip Code:53057-9726
Practice Address - Country:US
Practice Address - Phone:920-753-2771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-28
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental