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General NPI Number Information
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NPI Number | 1770369092
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Entity Type | Organization
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Legal Business Name | BLOOM DENTAL, LLC
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Dates
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Enumeration Date | 09/01/2023
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Last Update Date | 04/04/2024
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Provider Practice Location Address
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Address Line | 3970 FM 2181 STE 200
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City | HICKORY CREEK
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State | TX
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Zip | 75065-4249
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Country | US
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Telephone | 940-600-5365
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Fax |
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Provider Business Mailing Address
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Address Line | 3970 FM 2181 STE 200
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City | HICKORY CREEK
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State | TX
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Zip | 75065-4249
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Country | US
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Telephone | 940-600-5365
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ALYAA K MAFRAG
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Credential | DMD
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Telephone | 210-803-8889
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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