Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 2481 | SC |
NPI | 1154354520 |
---|---|
Provider Name | Dr. George Bumgardner |
First Address | Columbia, SC 29209-1638 |
Second Address | Columbia, SC 29209-1638 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/07/2006 |
Last Update Date | 17/04/2019 |