Provider Demographics
NPI:1760630610
Name:JOLY, STEPHANIE D (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:D
Last Name:JOLY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 LOIS ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-3500
Mailing Address - Country:US
Mailing Address - Phone:219-762-4266
Mailing Address - Fax:219-762-2252
Practice Address - Street 1:2646 LOIS ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-3500
Practice Address - Country:US
Practice Address - Phone:219-762-4266
Practice Address - Fax:219-762-2252
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0277511223G0001X
IN12011254A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice