Provider Demographics
NPI:1982869418
Name:BLOOM, JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1680 HUGUENOT RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-2427
Mailing Address - Country:US
Mailing Address - Phone:804-379-7120
Mailing Address - Fax:804-379-9835
Practice Address - Street 1:1680 HUGUENOT RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2427
Practice Address - Country:US
Practice Address - Phone:804-379-7120
Practice Address - Fax:804-379-9835
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014154721223S0112X
VA0438000369204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery