Basic Information
| Provider Information | |||||||||
| NPI: | 1164762829 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KEVIN OSBORN D.D.S., A DENTAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COTTONWOOD DENTAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2451 JAMACHA RD | ||||||||
| Address2: | SUTIE 104 | ||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920196319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194440500 | ||||||||
| FaxNumber: | 6194442803 | ||||||||
| Practice Location | |||||||||
| Address1: | 2451 JAMACHA ROAD | ||||||||
| Address2: | SUTIE 104 | ||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920194324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194440500 | ||||||||
| FaxNumber: | 6194442803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2013 | ||||||||
| LastUpdateDate: | 02/18/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OSBORN | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6194440500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.D.S. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 42866 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.