Provider Demographics
NPI:1366527780
Name:BLOOM, MICHAEL AARON (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:AARON
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9928 N GOVERNMENT WAY
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9604
Mailing Address - Country:US
Mailing Address - Phone:208-772-3583
Mailing Address - Fax:208-772-3224
Practice Address - Street 1:9928 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9604
Practice Address - Country:US
Practice Address - Phone:208-772-3583
Practice Address - Fax:208-772-3224
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-33941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010149088OtherREGENCE BLUE SHIELD
ID6I898OtherBLUE CROSS