MEDICARE: DR. NATHAN LEE BLOOM D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	6711-015	WI

General Provider Information

NPI Number	:	1215224829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NATHAN LEE BLOOM D.D.S.

Provider Business Mailing Address
First Line	:	3233 SUPERIOR AVE
Second Line	:
City	:	SHEBOYGAN
State	:	WI
Zip	:	53081-1858
Country	:	US
Telephone Number	:	920-457-0888
Fax Number	:	920-457-0896

Provider Business Practice Location Address
First Line	:	3233 SUPERIOR AVE
Second Line	:
City	:	SHEBOYGAN
State	:	WI
Zip	:	53081-1858
Country	:	US
Telephone Number	:	920-457-0888
Fax Number	:	920-457-0896

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2011
Last Update Date	:	05/11/2015

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