Healthcare Provider Details

I. General information

NPI: 1710416409
Provider Name (Legal Business Name): STEVEN JAMES BUMGARNER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1268 S MAIN ST
WAKE FOREST NC
27587-4997
US

IV. Provider business mailing address

1268 S MAIN ST
WAKE FOREST NC
27587-4997
US

V. Phone/Fax

Practice location:
  • Phone: 919-556-7820
  • Fax: 919-562-5399
Mailing address:
  • Phone: 919-556-7820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7359
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: