Healthcare Provider Details

I. General information

NPI: 1073447041
Provider Name (Legal Business Name): DYER PALM LEAF DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4715 E 91ST ST STE 110
TULSA OK
74137-2847
US

IV. Provider business mailing address

4715 E 91ST ST STE 110
TULSA OK
74137-2847
US

V. Phone/Fax

Practice location:
  • Phone: 833-923-4468
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SHAYLA MOORE
Title or Position: HUMAN RESOURCES
Credential:
Phone: 402-505-6843