Provider Demographics
NPI:1689058869
Name:OSBOURNE, BRIAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:OSBOURNE
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 1:919 CHAMBERS BLVD
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-2573
Mailing Address - Country:US
Mailing Address - Phone:502-348-6404
Mailing Address - Fax:
Practice Address - Street 1:919 CHAMBERS BLVD STE A
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2574
Practice Address - Country:US
Practice Address - Phone:270-402-1413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9636122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist