Provider Demographics
NPI:1720413768
Name:JIM H. POLLES, D.M.D., P.A.
Entity Type:Organization
Organization Name:JIM H. POLLES, D.M.D., P.A.
Other - Org Name:POLLES CENTER FOR GENERAL AND COSMETIC DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:H
Authorized Official - Last Name:POLLES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-362-1118
Mailing Address - Street 1:1836 CRANE RIDGE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4901
Mailing Address - Country:US
Mailing Address - Phone:601-362-1118
Mailing Address - Fax:601-362-3113
Practice Address - Street 1:1836 CRANE RIDGE DR
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4901
Practice Address - Country:US
Practice Address - Phone:601-362-1118
Practice Address - Fax:601-362-3113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3402-06261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00051807Medicaid