Provider Demographics
NPI:1922110667
Name:JOLLY, TODD LAWRENCE (DMD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:LAWRENCE
Last Name:JOLLY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1209
Mailing Address - Country:US
Mailing Address - Phone:973-235-0333
Mailing Address - Fax:973-562-9520
Practice Address - Street 1:629 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-1209
Practice Address - Country:US
Practice Address - Phone:973-235-0333
Practice Address - Fax:973-562-9520
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI16963122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist