Provider Demographics
NPI:1942939830
Name:JOLLEY, MAXIE GENE III (DMD)
Entity Type:Individual
Prefix:DR
First Name:MAXIE
Middle Name:GENE
Last Name:JOLLEY
Suffix:III
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 1:4005 GALANTIS DR APT 206D
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-0105
Mailing Address - Country:US
Mailing Address - Phone:252-722-1886
Mailing Address - Fax:
Practice Address - Street 1:208 PROFESSIONAL CIR
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-4302
Practice Address - Country:US
Practice Address - Phone:252-247-3010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC127661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty