MEDICARE: TULSA RESTORATIVE DENTISTRY PLLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1639837354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TULSA RESTORATIVE DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	2109 COMMERCE ST # 200
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75201-4305
Country	:	US
Telephone Number	:	972-248-1221
Fax Number	:

Provider Business Practice Location Address
First Line	:	9445 S MINGO RD
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74133-5826
Country	:	US
Telephone Number	:	918-286-7776
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WILLIAM ROBERT JENNINGS
Credential	:	DDS
Telephone Number	:	940-206-8956

Provider Enumeration Date	:	11/30/2021
Last Update Date	:	11/30/2021

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