Provider Demographics
NPI:1801277207
Name:JACKSON METRO DENTAL LLC
Entity type:Organization
Organization Name:JACKSON METRO DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:H
Authorized Official - Last Name:POLLES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:662-834-1585
Mailing Address - Street 1:PO BOX 297
Mailing Address - Street 2:102 WALL STREET
Mailing Address - City:LEXINGTON
Mailing Address - State:MS
Mailing Address - Zip Code:39095-0297
Mailing Address - Country:US
Mailing Address - Phone:662-834-1585
Mailing Address - Fax:662-834-1583
Practice Address - Street 1:102 WALL ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MS
Practice Address - Zip Code:39095-3540
Practice Address - Country:US
Practice Address - Phone:662-834-1585
Practice Address - Fax:662-834-1583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty