Healthcare Provider Details

I. General information

NPI: 1366265845
Provider Name (Legal Business Name): BLOOM DENTAL-PLAINFIELD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 N DAN JONES RD
PLAINFIELD IN
46168-1874
US

IV. Provider business mailing address

167 N DAN JONES RD
PLAINFIELD IN
46168-1874
US

V. Phone/Fax

Practice location:
  • Phone: 317-241-3111
  • Fax: 317-204-4311
Mailing address:
  • Phone: 317-241-3111
  • Fax: 317-204-4311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: BRANDT FINNEY
Title or Position: OWNER
Credential: DDS
Phone: 317-304-3111