Healthcare Provider Details

I. General information

NPI: 1205048584
Provider Name (Legal Business Name): DAVID ALAN BLOOM DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 ORCHARD PL
ORCHARD LAKE MI
48324-2356
US

IV. Provider business mailing address

2910 ORCHARD PL
ORCHARD LAKE MI
48324-2356
US

V. Phone/Fax

Practice location:
  • Phone: 248-613-5554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDB010636
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: