Healthcare Provider Details

I. General information

NPI: 1295430874
Provider Name (Legal Business Name): DANIEL OSBOURNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 04/16/2023
Certification Date: 04/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1780 MARINE CORPS DRIVE
SANTA RITA GU
96915
US

IV. Provider business mailing address

(ATTN DENTAL) 1780 MARINE CORPS DRIVE
SANTA RITA GU
96915
US

V. Phone/Fax

Practice location:
  • Phone: 671-339-5146
  • Fax: 671-339-3277
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: