Provider Demographics
NPI:1558476267
Name:KNOLLER, JAY BARRY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:BARRY
Last Name:KNOLLER
Suffix:
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 1:1236 ROYAL PALM BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-1602
Mailing Address - Country:US
Mailing Address - Phone:561-795-1404
Mailing Address - Fax:
Practice Address - Street 1:1236 ROYAL PALM BEACH BLVD
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-1602
Practice Address - Country:US
Practice Address - Phone:561-795-1404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN100881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice