Provider Demographics
NPI:1659050268
Name:OSBORNE, WYATT EDWARD
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:EDWARD
Last Name:OSBORNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29186 SANTIAM TERRACE RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-9001
Mailing Address - Country:US
Mailing Address - Phone:541-570-5818
Mailing Address - Fax:
Practice Address - Street 1:150 MARKET ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-2334
Practice Address - Country:US
Practice Address - Phone:541-570-5818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD118551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice