Healthcare Provider Details

I. General information

NPI: 1255007589
Provider Name (Legal Business Name): MT OMS SPECIALTY DENTAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 S 32ND ST W STE B
BILLINGS MT
59102-6875
US

IV. Provider business mailing address

1610 54TH AVE N
NASHVILLE TN
37209-1401
US

V. Phone/Fax

Practice location:
  • Phone: 406-245-4414
  • 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