Healthcare Provider Details

I. General information

NPI: 1750020798
Provider Name (Legal Business Name): DANIEL BLOOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2022
Last Update Date: 05/28/2022
Certification Date: 05/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11015 N SCOTTSDALE RD STE 101
SCOTTSDALE AZ
85254-5196
US

IV. Provider business mailing address

8100 E CAMELBACK RD # 100
SCOTTSDALE AZ
85251-2729
US

V. Phone/Fax

Practice location:
  • Phone: 480-544-2800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD011388
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: