MEDICARE: OSORIO SOUTH BOSTON DENTAL GROUP DMD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0700X	Prosthodontics

General Provider Information

NPI Number	:	1568939163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OSORIO SOUTH BOSTON DENTAL GROUP DMD PC

Provider Business Mailing Address
First Line	:	9 CHANNEL CTR ST STE 100
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02210-3436
Country	:	US
Telephone Number	:	617-268-1030
Fax Number	:	617-268-2924

Provider Business Practice Location Address
First Line	:	9 CHANNEL CTR ST STE 100
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02210-3436
Country	:	US
Telephone Number	:	617-268-1030
Fax Number	:	617-268-2924

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	JULIAN OSORIO
Credential	:	DMD, MSCD
Telephone Number	:	617-268-1030

Provider Enumeration Date	:	11/01/2018
Last Update Date	:	12/11/2024

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