Provider Demographics
NPI:1669482014
Name:POLLES, JIM H (DMD)
Entity type:Individual
Prefix:DR
First Name:JIM
Middle Name:H
Last Name:POLLES
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 1:1836 CRANE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4901
Mailing Address - Country:US
Mailing Address - Phone:601-362-1118
Mailing Address - Fax:601-362-3113
Practice Address - Street 1:1836 CRANE RIDGE DR
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4901
Practice Address - Country:US
Practice Address - Phone:601-362-1118
Practice Address - Fax:601-362-3113
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7754122300000X
MS3402-06122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS260182567OtherTAX ID
TN223877136OtherTAX ID