Healthcare Provider Details

I. General information

NPI: 1033372230
Provider Name (Legal Business Name): KELLY LEIGH BUMGARNER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2633 JEFFERSON STREET SUITE 801
ALEXANDRIA MN
56308
US

IV. Provider business mailing address

2380 COUNTY ROAD 9 NE
NELSON MN
56355-8167
US

V. Phone/Fax

Practice location:
  • Phone: 320-762-1717
  • Fax:
Mailing address:
  • Phone: 320-491-4234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD12536
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: