MEDICARE: DR. CHARLES HENRY BLOOM D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0700X	Prosthodontics	22DI01554800	NJ

General Provider Information

NPI Number	:	1174731954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES HENRY BLOOM D.M.D.

Provider Business Mailing Address
First Line	:	815 LIVINGSTON AVE
Second Line	:
City	:	NEW BRUNSWICK
State	:	NJ
Zip	:	08901-3344
Country	:	US
Telephone Number	:	732-249-6386
Fax Number	:	732-249-6283

Provider Business Practice Location Address
First Line	:	815 LIVINGSTON AVE
Second Line	:
City	:	NEW BRUNSWICK
State	:	NJ
Zip	:	08901-3344
Country	:	US
Telephone Number	:	732-249-6386
Fax Number	:	732-249-6283

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	07/08/2007

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