MEDICARE: DR. KERRY MARK BLOOM D.D.S.

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	122300000X	Dentist	10986	TX

General Provider Information

NPI Number	:	1386652402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KERRY MARK BLOOM D.D.S.

Provider Business Mailing Address
First Line	:	6560 FANNIN ST STE 1434
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-2713
Country	:	US
Telephone Number	:	713-795-0130
Fax Number	:	713-795-0470

Provider Business Practice Location Address
First Line	:	6560 FANNIN ST STE 1434
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-2713
Country	:	US
Telephone Number	:	713-795-0130
Fax Number	:	713-795-0470

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

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	07/08/2007

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