MEDICARE: MD OMS SDS, 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1225801236
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MD OMS SDS, LLC

Provider Business Mailing Address
First Line	:	1610 54TH AVE N STE 205
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37209-1442
Country	:	US
Telephone Number	:	615-678-0759
Fax Number	:

Provider Business Practice Location Address
First Line	:	5397 TWIN KNOLLS RD STE 18
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21045-3256
Country	:	US
Telephone Number	:	410-730-6001
Fax Number	:

Authorized Official
Title or Position	:	DIRECT OF CRED AND PROV REL
Name	:	CHARLOTTE E VIAL
Credential	:
Telephone Number	:	504-638-0303

Provider Enumeration Date	:	11/01/2023
Last Update Date	:	11/01/2023

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