Provider Demographics
NPI:1578745162
Name:BUMGARNER, WILLIAM G (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:G
Last Name:BUMGARNER
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 1:6770 SELMAN DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1756
Mailing Address - Country:US
Mailing Address - Phone:770-949-7359
Mailing Address - Fax:
Practice Address - Street 1:6770 SELMAN DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1756
Practice Address - Country:US
Practice Address - Phone:770-949-7359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0086021223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000153414FMedicaid
GA9208296OtherDORAL
GA000153414EMedicaid
GA102300OtherAVESIS