Healthcare Provider Details

I. General information

NPI: 1174686984
Provider Name (Legal Business Name): SANDRA MARTIN BUMGARNER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 N SANDHILLS BLVD
ABERDEEN NC
28315-2547
US

IV. Provider business mailing address

908 N SANDHILLS BLVD
ABERDEEN NC
28315-2547
US

V. Phone/Fax

Practice location:
  • Phone: 910-944-5600
  • Fax: 910-944-9334
Mailing address:
  • Phone: 910-944-5600
  • Fax: 910-944-9334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number3827
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: