Provider Demographics
NPI:1407962988
Name:BUMGARDNER, KORY LEE (DENTIST)
Entity Type:Individual
Prefix:DR
First Name:KORY
Middle Name:LEE
Last Name:BUMGARDNER
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 W 12TH ST
Mailing Address - Street 2:SUITE #3
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-3660
Mailing Address - Country:US
Mailing Address - Phone:402-462-6484
Mailing Address - Fax:402-462-2444
Practice Address - Street 1:2217 W 12TH ST
Practice Address - Street 2:SUITE #3
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-3660
Practice Address - Country:US
Practice Address - Phone:402-462-6484
Practice Address - Fax:402-462-2444
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE63161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-0841441-00Medicaid