Provider Demographics
NPI:1891930293
Name:JOLLY, TESA HARRIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:TESA
Middle Name:HARRIS
Last Name:JOLLY
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 1:217 W JEFFERSON ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478-2835
Mailing Address - Country:US
Mailing Address - Phone:931-363-1564
Mailing Address - Fax:931-363-1559
Practice Address - Street 1:217 W JEFFERSON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478-2835
Practice Address - Country:US
Practice Address - Phone:931-363-1564
Practice Address - Fax:931-363-1559
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-13
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8941122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1513043Medicaid