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General NPI Number Information
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NPI Number | 1104189430
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Entity Type | Organization
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Legal Business Name | BLOOMING DENTAL PLLC
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Dates
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Enumeration Date | 06/21/2012
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Last Update Date | 06/21/2012
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Provider Practice Location Address
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Address Line | 150 E 58TH ST 8TH FLOOR ANNEX
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City | NEW YORK
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State | NY
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Zip | 10155-0002
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Country | US
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Telephone | 646-861-2404
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Fax |
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Provider Business Mailing Address
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Address Line | 16411 CROCHERON AVE
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City | FLUSHING
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State | NY
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Zip | 11358-2015
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Country | US
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Telephone | 646-861-2404
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. MARIA MARCIAL
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Credential | DDS
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Telephone | 646-861-2404
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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 | 047318
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License Number State | NY
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