Healthcare Provider Details

I. General information

NPI: 1508178559
Provider Name (Legal Business Name): BENJAMIN JOSEPH BUMGARDNER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2010
Last Update Date: 07/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 DAVID RAINES RD
SHREVEPORT LA
71107-5899
US

IV. Provider business mailing address

1625 DAVID RAINES RD
SHREVEPORT LA
71107-5899
US

V. Phone/Fax

Practice location:
  • Phone: 318-425-2252
  • Fax: 318-227-3357
Mailing address:
  • Phone: 318-425-2252
  • Fax: 318-227-3357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6079
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: