Box 24i ID Qualifier (Shaded Section) – Dental claim

From January 1, 2007 to May 22, 2007 enter in the SHADED section of the line “1D” for Medicaid
provider in this box. On May 23, 2007 and afterwards use qualifier “ZZ” for the taxonomy
code.

See the chart below for dental taxonomy codes that may be used.

Category/Description Code                                                                        Code
Dentists: A dentist is a person
qualified by a doctorate in dental                                                             122300000X
surgery (D.D.S.) or dental medicine
(D.M.D.) licensed by the state to
practice dentistry and practicing
within the scope of that license.

Dental Specialty (see following list)                                                            Various

Prosthodontics                                                                                           1223P0700X

Oral & Maxillofacial Pathology                                                                  1223P0106X

Oral & Maxillofacial Radiology                                                                 1223D0008X

Oral & Maxillofacial Surgery                                                                    1223S0112X