Provider Demographics
NPI:1417097957
Name:JOLLY, JAMES M JR (DMD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:JOLLY
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 1 2 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701
Mailing Address - Country:US
Mailing Address - Phone:606-439-4581
Mailing Address - Fax:606-439-2873
Practice Address - Street 1:1724 12 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701
Practice Address - Country:US
Practice Address - Phone:606-439-4581
Practice Address - Fax:606-439-2873
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY56041223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60056041Medicaid