Provider Demographics
NPI:1306852744
Name:ROLLO, JON RAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:RAY
Last Name:ROLLO
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 1:1717 SAINT JAMES PL
Mailing Address - Street 2:#300
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77056-3404
Mailing Address - Country:US
Mailing Address - Phone:713-621-4424
Mailing Address - Fax:713-621-4430
Practice Address - Street 1:1717 SAINT JAMES PL
Practice Address - Street 2:#300
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77056-3404
Practice Address - Country:US
Practice Address - Phone:713-621-4424
Practice Address - Fax:713-621-4430
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10449122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist