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General NPI Number Information
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NPI Number | 1851628903
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Entity Type | Organization
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Legal Business Name | BLOOMINGTON FAMILY DENTAL
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Dates
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Enumeration Date | 11/11/2009
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Last Update Date | 11/11/2009
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Provider Practice Location Address
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Address Line | 4000 SOUTH OLD STATE RD US 37
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City | BLOOMINGTON
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State | IN
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Zip | 47401-7412
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Country | US
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Telephone | 812-824-1600
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Fax | 812-824-1615
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Provider Business Mailing Address
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Address Line | 4000 S. OLD STATE RD US 37
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City | BLOOMINGTON
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State | IN
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Zip | 47401-7412
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Country | US
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Telephone | 812-824-1600
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Fax | 812-824-1615
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Authorized Official
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Title or Position | DENTIST
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Name | DR. RYAN EDWARD KLOBOVES
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Credential | DDS
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Telephone | 812-824-1600
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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 | 12010746B
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License Number State | IN
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