MEDICARE: OR OMS 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1568339711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OR OMS SPECIALTY DENTAL SERVICES, 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	:	250 CHURCH ST SE STE 102
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-3758
Country	:	US
Telephone Number	:	503-581-1999
Fax Number	:	503-581-1107

Authorized Official
Title or Position	:	SR. DIRECTOR OF CREDENTIALING
Name	:	CHARLOTTE DASCH
Credential	:
Telephone Number	:	615-678-0759

Provider Enumeration Date	:	10/22/2025
Last Update Date	:	10/22/2025

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