Healthcare Provider Details

I. General information

NPI: 1548146426
Provider Name (Legal Business Name): GA OMS SDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2025
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 PEACHTREE INDUSTRIAL BLVD STE 100
SUWANEE GA
30024-3793
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 770-232-1191
  • 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: SR. DIRECTOR OF CREDENTIALING
Credential:
Phone: 504-638-0303