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General NPI Number Information
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NPI Number | 1336002302
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Entity Type | Organization
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Legal Business Name | RESTORE DERMATOLOGY CLIONIC LLC
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Dates
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Enumeration Date | 12/06/2025
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Last Update Date | 12/06/2025
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Provider Practice Location Address
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Address Line | 4700 W URBANA ST STE 100
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City | BROKEN ARROW
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State | OK
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Zip | 74012-5520
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Country | US
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Telephone | 539-281-3101
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Fax |
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Provider Business Mailing Address
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Address Line | 4700 W URBANA ST STE 100
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City | BROKEN ARROW
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State | OK
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Zip | 74012-5520
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Country | US
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Telephone | 539-281-3101
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | JESSICA GRAVES
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Credential | PA-C
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Telephone | 539-281-3101
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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