Provider Demographics
NPI:1073663738
Name:OSBORNE, KRAIG D (DMD)
Entity Type:Individual
Prefix:
First Name:KRAIG
Middle Name:D
Last Name:OSBORNE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 W ILES AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4263
Mailing Address - Country:US
Mailing Address - Phone:217-546-0351
Mailing Address - Fax:217-546-0352
Practice Address - Street 1:2501 W ILES AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4263
Practice Address - Country:US
Practice Address - Phone:217-546-0351
Practice Address - Fax:217-546-0352
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190207971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice