Provider Demographics
NPI:1457637522
Name:JAMES M. JOLLY, JR., D.M.D, PSC
Entity Type:Organization
Organization Name:JAMES M. JOLLY, JR., D.M.D, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MARVIN
Authorized Official - Last Name:JOLLY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-439-4581
Mailing Address - Street 1:1724 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-1278
Mailing Address - Country:US
Mailing Address - Phone:606-439-4581
Mailing Address - Fax:606-439-2873
Practice Address - Street 1:1724 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-1278
Practice Address - Country:US
Practice Address - Phone:606-439-4581
Practice Address - Fax:606-439-2873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY56041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty