Healthcare Provider Details

I. General information

NPI: 1104759810
Provider Name (Legal Business Name): BENJAMIN JACOB BLOOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E BROAD ST
RICHMOND VA
23219-1930
US

IV. Provider business mailing address

1677 EWING PARK LOOP
MIDLOTHIAN VA
23113-3449
US

V. Phone/Fax

Practice location:
  • Phone: 301-802-7282
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401420054
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: