MEDICARE: RESTORE DERMATOLOGY CLINIC 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	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1336002302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTORE DERMATOLOGY CLINIC LLC

Provider Business Mailing Address
First Line	:	4700 W URBANA ST STE 100
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-5520
Country	:	US
Telephone Number	:	539-281-3101
Fax Number	:

Provider Business Practice Location Address
First Line	:	4700 W URBANA ST STE 100
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-5520
Country	:	US
Telephone Number	:	539-281-3101
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	JESSICA GRAVES
Credential	:	PA-C
Telephone Number	:	539-281-3101

Provider Enumeration Date	:	12/06/2025
Last Update Date	:	12/17/2025

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