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General NPI Number Information
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NPI Number | 1679342042
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Entity Type | Organization
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Legal Business Name | BLOOM ENDO, LLC
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Dates
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Enumeration Date | 12/27/2023
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Last Update Date | 02/13/2024
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Provider Practice Location Address
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Address Line | 617 MYERS RD STE B
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City | SUMMERVILLE
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State | SC
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Zip | 29486-8902
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Country | US
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Telephone | 843-647-6052
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Fax |
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Provider Business Mailing Address
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Address Line | 617 MYERS RD STE B
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City | SUMMERVILLE
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State | SC
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Zip | 29486-8902
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Country | US
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Telephone | 843-647-6052
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Fax |
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Authorized Official
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Title or Position | ENDODONTIST/OWNER
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Name | DR. TIMOTHY CURTIS GIBSON JR.
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Credential | DDS, MS
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Telephone | 843-647-6052
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number |
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License Number State |
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