1083873939 NPI number — CHERILEE C BLOOM DDS PLLC

Table of content: (NPI 1083873939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083873939 NPI number — CHERILEE C BLOOM DDS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHERILEE C BLOOM DDS PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083873939
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
815 W CANFIELD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COEUR D ALENE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83815-9765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
108-762-2544
Provider Business Mailing Address Fax Number:
208-762-9563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
815 W CANFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COEUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83815-9765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
108-762-2544
Provider Business Practice Location Address Fax Number:
208-762-9563
Provider Enumeration Date:
06/05/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BLOOM
Authorized Official First Name:
CHERI
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER/MEMBER
Authorized Official Telephone Number:
208-762-2544

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  3510 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)