Provider Demographics
NPI:1699261347
Name:BLOOMING FAMILY DENTAL LLC
Entity type:Organization
Organization Name:BLOOMING FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:K
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:646-673-4496
Mailing Address - Street 1:749 BLOOMFIELD AVE STE D
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-6717
Mailing Address - Country:US
Mailing Address - Phone:973-787-8437
Mailing Address - Fax:
Practice Address - Street 1:749 BLOOMFIELD AVE STE D
Practice Address - Street 2:
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-6717
Practice Address - Country:US
Practice Address - Phone:646-673-4496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-05
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025650001223G0001X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty