Provider Demographics
NPI:1104691096
Name:BRANDON JOLLEY DDS PA LLC
Entity type:Organization
Organization Name:BRANDON JOLLEY DDS PA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:JOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-401-4923
Mailing Address - Street 1:700 MOUNT HOPE AVE STE 610
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5673
Mailing Address - Country:US
Mailing Address - Phone:207-945-5952
Mailing Address - Fax:207-945-5761
Practice Address - Street 1:700 MOUNT HOPE AVE STE 610
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5673
Practice Address - Country:US
Practice Address - Phone:207-945-5952
Practice Address - Fax:207-945-5761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-20
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty