MEDICARE: CARL BLOOM D.M.D.

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	1223P0221X	Pediatric Dentistry	17269	TX

General Provider Information

NPI Number	:	1932227360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARL BLOOM D.M.D.

Provider Business Mailing Address
First Line	:	800 N 2ND ST
Second Line	:
City	:	BELLAIRE
State	:	TX
Zip	:	77401-2802
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9641 HILLCROFT ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77096-3805
Country	:	US
Telephone Number	:	713-721-2275
Fax Number	:

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

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	07/08/2007

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