Provider Demographics
NPI:1386964583
Name:OSBORNE, TY DODSON (DDS)
Entity type:Individual
Prefix:DR
First Name:TY
Middle Name:DODSON
Last Name:OSBORNE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 SHELDON PL
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3238
Mailing Address - Country:US
Mailing Address - Phone:631-896-6096
Mailing Address - Fax:
Practice Address - Street 1:90 MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-2719
Practice Address - Country:US
Practice Address - Phone:631-269-6812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0556221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice