Provider Demographics
NPI:1528205853
Name:JOLLEY, ROBERT KIRKHAM (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:KIRKHAM
Last Name:JOLLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:KIRKHAM
Other - Last Name:JOLLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:40 WEST 100 NORTH
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078
Mailing Address - Country:US
Mailing Address - Phone:435-789-2888
Mailing Address - Fax:435-789-7281
Practice Address - Street 1:40 WEST 100 NORTH
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078
Practice Address - Country:US
Practice Address - Phone:435-789-2888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT139366122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist