Provider Demographics
NPI:1932774395
Name:JOLLEY, RICHARD KEATON (DMD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:KEATON
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 1:600 MANOR GLEN DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-3517
Mailing Address - Country:US
Mailing Address - Phone:801-361-6446
Mailing Address - Fax:
Practice Address - Street 1:601 28 1/4 RD UNIT E
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-6022
Practice Address - Country:US
Practice Address - Phone:570-523-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002041471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics