Provider Demographics
NPI:1851472658
Name:R K JOLLEY DDS PC
Entity Type:Organization
Organization Name:R K JOLLEY DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO PRESIDENTS
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:K
Authorized Official - Last Name:JOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PC
Authorized Official - Phone:435-789-2888
Mailing Address - Street 1:400 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:
Practice Address - Street 1:400 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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13733899221223G0001X
UT13936699221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty