Healthcare Provider Details

I. General information

NPI: 1194057174
Provider Name (Legal Business Name): CRAIG Y. BLOOM,DMD, RICHARD M.A. BERGER,DDS & BRYAN R. KREY, DMD, APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 02/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2522 DANA ST SUITE 202
BERKELEY CA
94704-2895
US

IV. Provider business mailing address

2522 DANA ST SUITE 202
BERKELEY CA
94704-2895
US

V. Phone/Fax

Practice location:
  • Phone: 510-848-1055
  • Fax: 510-848-1055
Mailing address:
  • Phone: 510-848-1055
  • Fax: 510-848-1055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number31571
License Number StateCA

VIII. Authorized Official

Name: DR. CRAIG YALE BLOOM
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 510-848-1055