Healthcare Provider Details

I. General information

NPI: 1407962988
Provider Name (Legal Business Name): KORY LEE BUMGARDNER DENTIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2217 W 12TH ST SUITE #3
HASTINGS NE
68901-3660
US

IV. Provider business mailing address

2217 W 12TH ST SUITE #3
HASTINGS NE
68901-3660
US

V. Phone/Fax

Practice location:
  • Phone: 402-462-6484
  • Fax: 402-462-2444
Mailing address:
  • Phone: 402-462-6484
  • Fax: 402-462-2444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6316
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: