Provider Demographics
NPI:1760498596
Name:JOLLY DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:JOLLY DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:JOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-758-7462
Mailing Address - Street 1:4601 FAIRWAY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-8052
Mailing Address - Country:US
Mailing Address - Phone:501-758-7462
Mailing Address - Fax:501-758-1696
Practice Address - Street 1:4601 FAIRWAY AVE
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-8052
Practice Address - Country:US
Practice Address - Phone:501-758-7462
Practice Address - Fax:501-758-1696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty