Provider Demographics
NPI:1174731954
Name:BLOOM, CHARLES HENRY (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:HENRY
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 1:815 LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-3344
Mailing Address - Country:US
Mailing Address - Phone:732-249-6386
Mailing Address - Fax:732-249-6283
Practice Address - Street 1:815 LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-3344
Practice Address - Country:US
Practice Address - Phone:732-249-6386
Practice Address - Fax:732-249-6283
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI015548001223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics