Provider Demographics
NPI:1003392218
Name:OSEROWSKY, GRANT BRENNAN (DDS)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:BRENNAN
Last Name:OSEROWSKY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5211 S BROOKMERE ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-5097
Mailing Address - Country:US
Mailing Address - Phone:417-825-4000
Mailing Address - Fax:
Practice Address - Street 1:614 E EMMA AVE STE 300
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-4469
Practice Address - Country:US
Practice Address - Phone:479-751-7417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR42981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice