MEDICARE: OR SPECIALTY DENTAL SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center

General Provider Information

NPI Number	:	1053066894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OR SPECIALTY DENTAL SERVICES LLC

Provider Business Mailing Address
First Line	:	401 CHURCH ST STE 1900
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37219-2226
Country	:	US
Telephone Number	:	615-678-0759
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 CHURCH ST SE STE 102
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-3758
Country	:	US
Telephone Number	:	503-581-1999
Fax Number	:

Authorized Official
Title or Position	:	OWNER OF ENTITY
Name	:	JAMES M EYRE JR.
Credential	:	DMD
Telephone Number	:	503-580-6099

Provider Enumeration Date	:	02/21/2022
Last Update Date	:	02/21/2022

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Directions to “OR SPECIALTY DENTAL SERVICES LLC ” Practice Location

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