Provider Demographics
NPI:1073520300
Name:JOLLY, SCOTT
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:JOLLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 FAIRWAY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-8052
Mailing Address - Country:US
Mailing Address - Phone:501-758-7462
Mailing Address - Fax:501-758-1696
Practice Address - Street 1:4601 FAIRWAY AVE
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-8052
Practice Address - Country:US
Practice Address - Phone:501-758-7462
Practice Address - Fax:501-758-1696
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR32581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice