Healthcare Provider Details

I. General information

NPI: 1336808815
Provider Name (Legal Business Name): AZ OMS SPECIALTY DENTAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2021
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1876 E INNOVATION PARK DR
ORO VALLEY AZ
85755-1963
US

IV. Provider business mailing address

1610 54TH AVE N STE 205
NASHVILLE TN
37209-1442
US

V. Phone/Fax

Practice location:
  • Phone: 520-745-2454
  • Fax:
Mailing address:
  • Phone: 504-638-0303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: CHARLOTTE DASCH
Title or Position: DIRECTOR OF PROVIDER RELATIONS
Credential:
Phone: 504-638-0303