Provider Demographics
NPI:1740700210
Name:BUMBAUGH, COURTNEY (DDS)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:BUMBAUGH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 S 500 E
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46725-9049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-1314
Practice Address - Country:US
Practice Address - Phone:260-212-5058
Practice Address - Fax:260-232-0053
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012735A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
46725OtherZIP