Restore Dermatology Clinic LLC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

Legal business name

RESTORE DERMATOLOGY CLINIC LLC

Practice address

4700 W Urbana St Ste 100
Broken Arrow, OK 74012-5520

Phone

(539) 281-3101

NPI assigned

Dec 6, 2025

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Jessica Graves, PA-CNPI 1407120066

Title

Sole Member

Phone

(539) 281-3101

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in OK

Enrollment records 1

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Jessica Laura Graves, PA-C

  • Medical Physician Assistant
  • Broken Arrow, OK
  • NPI 1407120066
  Medicare reassignment NPD Authorized official
• Lee Theodore Bottem, D.O.

  • Ophthalmology Physician
  • Broken Arrow, OK
  • NPI 1679745418
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1764979200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1765929600000",
    "number": "1336002302",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4700 W URBANA ST STE 100",
            "city": "BROKEN ARROW",
            "state": "OK",
            "postal_code": "740125520",
            "telephone_number": "539-281-3101"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4700 W URBANA ST STE 100",
            "city": "BROKEN ARROW",
            "state": "OK",
            "postal_code": "740125520",
            "telephone_number": "539-281-3101"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RESTORE DERMATOLOGY CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2025-12-06",
        "last_updated": "2025-12-17",
        "certification_date": "2025-12-17",
        "status": "A",
        "authorized_official_last_name": "GRAVES",
        "authorized_official_first_name": "JESSICA",
        "authorized_official_title_or_position": "SOLE MEMBER",
        "authorized_official_telephone_number": "539-281-3101",
        "authorized_official_credential": "PA-C"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Snoda Dawn Reyburn
• April Sunshine Reynolds

• Dermatology Physician in Broken Arrow, OK
• Providers in Broken Arrow, OK by specialty
• Dermatology Physician in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 17, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.