Provider Demographics
NPI:1609256486
Name:OSBORN, SHELLY (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:
Last Name:OSBORN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2162 S LAMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5224
Mailing Address - Country:US
Mailing Address - Phone:662-236-1969
Mailing Address - Fax:
Practice Address - Street 1:2162 S LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5224
Practice Address - Country:US
Practice Address - Phone:662-236-1969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3795-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist