Provider Demographics
NPI:1043430176
Name:JOLLY, WILLIAM HARRISON (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:HARRISON
Last Name:JOLLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 SOUTH MORRIS STREET
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-2238
Mailing Address - Country:US
Mailing Address - Phone:573-581-0511
Mailing Address - Fax:573-581-0511
Practice Address - Street 1:1415 SOUTH MORRIS STREET
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-2238
Practice Address - Country:US
Practice Address - Phone:573-581-0511
Practice Address - Fax:573-581-0511
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12295122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist