Provider Demographics
NPI:1306954235
Name:BLOOM, DENNIS LYNN (DC)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:LYNN
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22201 W OUTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4251
Mailing Address - Country:US
Mailing Address - Phone:313-561-2199
Mailing Address - Fax:313-561-9615
Practice Address - Street 1:22201 W OUTER DRIVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4251
Practice Address - Country:US
Practice Address - Phone:313-561-2199
Practice Address - Fax:313-561-9615
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDB006567111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950Q25037OtherBC/BS
MI950Q25037OtherBC/BS
OQ25037Medicare ID - Type Unspecified