Healthcare Provider Details

I. General information

NPI: 1588010565
Provider Name (Legal Business Name): BLOOMING DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N VISTA RIDGE BLVD STE 100
CEDAR PARK TX
78613-0000
US

IV. Provider business mailing address

111 N VISTA RIDGE BLVD STE 100
CEDAR PARK TX
78613-0000
US

V. Phone/Fax

Practice location:
  • Phone: 512-250-2356
  • Fax:
Mailing address:
  • Phone: 512-250-2356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19039
License Number StateTX

VIII. Authorized Official

Name: JAMES J LEE
Title or Position: OWNER
Credential:
Phone: 512-250-2356