Provider Demographics
NPI:1912304254
Name:JOLLEY, RYAN (DMD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:JOLLEY
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 1:10116 OCICAT AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89166-5254
Mailing Address - Country:US
Mailing Address - Phone:702-574-4768
Mailing Address - Fax:
Practice Address - Street 1:1001 SHADOW LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4124
Practice Address - Country:US
Practice Address - Phone:702-774-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLL-385-141223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics