Provider Demographics
NPI:1578329603
Name:MT OMS SPECIALTY DENTAL SERVICES, PLLC
Entity Type:Organization
Organization Name:MT OMS SPECIALTY DENTAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING & PR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:E
Authorized Official - Last Name:VIAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-638-0303
Mailing Address - Street 1:1610 54TH AVE N STE 205
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-1442
Mailing Address - Country:US
Mailing Address - Phone:615-678-0759
Mailing Address - Fax:
Practice Address - Street 1:152 S 32ND ST W STE B
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-6875
Practice Address - Country:US
Practice Address - Phone:406-655-0170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MT OMS SPECIALTY DENTAL SERVICES, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty