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General NPI Number Information
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NPI Number | 1083873939
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Entity Type | Organization
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Legal Business Name | CHERILEE C BLOOM DDS PLLC
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Dates
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Enumeration Date | 06/05/2008
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Last Update Date | 04/07/2017
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Provider Practice Location Address
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Address Line | 815 W CANFIELD AVE
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City | COEUR D ALENE
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State | ID
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Zip | 83815-9765
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Country | US
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Telephone | 108-762-2544
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Fax | 208-762-9563
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Provider Business Mailing Address
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Address Line | 815 W CANFIELD AVE
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City | COEUR D ALENE
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State | ID
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Zip | 83815-9765
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Country | US
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Telephone | 108-762-2544
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Fax | 208-762-9563
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | CHERI C BLOOM
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Credential | DDS
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Telephone | 208-762-2544
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3510
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License Number State | ID
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