Provider Demographics
NPI:1346248994
Name:OSBORNE, COLIN PORTER III (DDS,PA)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:PORTER
Last Name:OSBORNE
Suffix:III
Gender:M
Credentials:DDS,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 569
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28359-0569
Mailing Address - Country:US
Mailing Address - Phone:910-738-9396
Mailing Address - Fax:910-738-9395
Practice Address - Street 1:407 W 27TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3019
Practice Address - Country:US
Practice Address - Phone:910-738-9396
Practice Address - Fax:910-738-9395
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC37031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8996531Medicaid
NC96531OtherBCBSNC
NC2416443Medicare ID - Type Unspecified
NCU31514Medicare UPIN