Provider Demographics
NPI:1316432347
Name:BUMGARNER, KELSEY VENEMAN (DMD)
Entity type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:VENEMAN
Last Name:BUMGARNER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:VENEMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:992 25 RD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-9667
Mailing Address - Country:US
Mailing Address - Phone:651-216-4585
Mailing Address - Fax:
Practice Address - Street 1:288 W PABOR AVE
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-2153
Practice Address - Country:US
Practice Address - Phone:970-858-8484
Practice Address - Fax:970-858-6436
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002053571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice