Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 2901010395 | MI |
NPI | 1215950100 |
---|---|
Provider Name | William S Bloom |
First Address | Warren, MI 48093 |
Second Address | Warren, MI 48093 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2642399 | (05) | MI |
T82796 | (02) |