Provider Demographics
NPI:1508178559
Name:BUMGARDNER, BENJAMIN JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JOSEPH
Last Name:BUMGARDNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 DAVID RAINES RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-5899
Mailing Address - Country:US
Mailing Address - Phone:318-425-2252
Mailing Address - Fax:318-227-3357
Practice Address - Street 1:1625 DAVID RAINES RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-5899
Practice Address - Country:US
Practice Address - Phone:318-425-2252
Practice Address - Fax:318-227-3357
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA60791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice