Provider Demographics
NPI:1962557587
Name:BLOOMQUIST, MARK ARNOLD (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ARNOLD
Last Name:BLOOMQUIST
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:315 ACCESS DR
Mailing Address - City:SPICER
Mailing Address - State:MN
Mailing Address - Zip Code:56288
Mailing Address - Country:US
Mailing Address - Phone:320-796-2158
Mailing Address - Fax:320-796-2158
Practice Address - Street 1:315 ACCESS DR
Practice Address - Street 2:
Practice Address - City:SPICER
Practice Address - State:MN
Practice Address - Zip Code:56288
Practice Address - Country:US
Practice Address - Phone:320-796-2158
Practice Address - Fax:320-796-2158
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN93901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice