Provider Demographics
NPI:1912519067
Name:100 SOUTH BLOOMFIELD PROFESSIONAL, LLC
Entity Type:Organization
Organization Name:100 SOUTH BLOOMFIELD PROFESSIONAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUMBOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-632-3344
Mailing Address - Street 1:100 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-6242
Mailing Address - Country:US
Mailing Address - Phone:505-632-3344
Mailing Address - Fax:
Practice Address - Street 1:100 S 1ST ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-6242
Practice Address - Country:US
Practice Address - Phone:505-632-3344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty