Healthcare Provider Details

I. General information

NPI: 1780795229
Provider Name (Legal Business Name): THOMAS ROBERT BLOOM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 OLD ROUTE 22
PAWLING NY
12564
US

IV. Provider business mailing address

217 OLD ROUTE 22
PAWLING NY
12564
US

V. Phone/Fax

Practice location:
  • Phone: 917-846-8635
  • Fax:
Mailing address:
  • Phone: 917-846-8635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number029678
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: