Healthcare Provider Details

I. General information

NPI: 1366450371
Provider Name (Legal Business Name): THOMAS E OSBORNE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 08/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2295 PARKLAKE DR NE SUITE 240
ATLANTA GA
30345-2844
US

IV. Provider business mailing address

2295 PARKLAKE DR NE SUITE 240
ATLANTA GA
30345-2844
US

V. Phone/Fax

Practice location:
  • Phone: 770-723-9965
  • Fax: 770-270-6851
Mailing address:
  • Phone: 770-723-9965
  • Fax: 770-270-6851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number10606
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: