=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255085684
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRANT B OSEROWSKY DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2022
-----------------------------------------------------
Last Update Date | 02/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1404 SE EAGLE WAY STE 2
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-4841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-553-9202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 W OXFORD DR
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72758-9530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-825-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. GRANT OSEROWSKY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 417-825-4000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------