Provider Demographics
NPI:1154025518
Name:JOLLEY, TYLER PAUL
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:PAUL
Last Name:JOLLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-1513
Mailing Address - Country:US
Mailing Address - Phone:806-358-7633
Mailing Address - Fax:
Practice Address - Street 1:2401 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-1513
Practice Address - Country:US
Practice Address - Phone:806-358-7633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-29
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40507122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist