Healthcare Provider Details

I. General information

NPI: 1841344751
Provider Name (Legal Business Name): CRAIG YALE BLOOM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2522 DANA ST SUITE 202
BERKELEY CA
94704-2803
US

IV. Provider business mailing address

2522 DANA ST SUITE 202
BERKELEY CA
94704-2803
US

V. Phone/Fax

Practice location:
  • Phone: 510-848-1055
  • Fax: 510-848-9100
Mailing address:
  • Phone: 510-848-1055
  • Fax: 510-848-9100

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:
Title or Position:
Credential:
Phone: