Basic Information
| Provider Information | |||||||||
| NPI: | 1770153314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OSBORNE | ||||||||
| FirstName: | KODY | ||||||||
| MiddleName: | QUENTIN | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 647 W BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422404 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1075 S WELLS ST | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836427997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554336825 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2021 | ||||||||
| LastUpdateDate: | 10/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DEN-DEN-LIC-21478 | MT | N | Dental Providers | Dentist | General Practice | 1223G0001X | D11460 | OR | N | Dental Providers | Dentist | General Practice | 1223G0001X | D5324 | ID | Y | Dental Providers | Dentist | General Practice |
No ID Information.