MEDICARE: DYER PALM LEAF DENTAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1073447041
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYER PALM LEAF DENTAL LLC

Provider Business Mailing Address
First Line	:	4715 E 91ST ST STE 110
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-2847
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4715 E 91ST ST STE 110
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-2847
Country	:	US
Telephone Number	:	833-923-4468
Fax Number	:

Authorized Official
Title or Position	:	HUMAN RESOURCES
Name	:	SHAYLA MOORE
Credential	:
Telephone Number	:	402-505-6843

Provider Enumeration Date	:	06/12/2026
Last Update Date	:	06/12/2026

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