Provider Demographics
NPI:1386934016
Name:ROY R JOLLEY DDS
Entity type:Organization
Organization Name:ROY R JOLLEY DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-664-5615
Mailing Address - Street 1:5 VAN CIR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-5211
Mailing Address - Country:US
Mailing Address - Phone:501-664-5615
Mailing Address - Fax:501-664-9118
Practice Address - Street 1:5 VAN CIR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207-5211
Practice Address - Country:US
Practice Address - Phone:501-664-5615
Practice Address - Fax:501-664-9118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1981261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110054631Medicaid