Healthcare Provider Details

I. General information

NPI: 1639012636
Provider Name (Legal Business Name): DYER PALM LEAF DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 EUBANK BLVD NE STE 17
ALBUQUERQUE NM
87111-3427
US

IV. Provider business mailing address

6606 S 168TH ST STE 100
OMAHA NE
68135-5420
US

V. Phone/Fax

Practice location:
  • Phone: 402-505-6843
  • Fax:
Mailing address:
  • Phone: 402-505-6843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM DYER
Title or Position: OWNER
Credential: DDS
Phone: 402-505-6843