Provider Demographics
NPI:1982283032
Name:BLOOMING DENTAL, PLLC
Entity Type:Organization
Organization Name:BLOOMING DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-250-2356
Mailing Address - Street 1:111 N VISTA RIDGE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-2425
Mailing Address - Country:US
Mailing Address - Phone:512-250-2356
Mailing Address - Fax:512-532-6516
Practice Address - Street 1:111 N VISTA RIDGE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2425
Practice Address - Country:US
Practice Address - Phone:512-250-2356
Practice Address - Fax:512-532-6516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX19039OtherTEXAS STATE BOARD LICENSE