MEDICARE: DR. JON RAY ROLLO D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	10449	TX

General Provider Information

NPI Number	:	1306852744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JON RAY ROLLO D.D.S.

Provider Business Mailing Address
First Line	:	1717 SAINT JAMES PL
Second Line	:	#300
City	:	HOUSTON
State	:	TX
Zip	:	77056-3404
Country	:	US
Telephone Number	:	713-621-4424
Fax Number	:	713-621-4430

Provider Business Practice Location Address
First Line	:	1717 SAINT JAMES PL
Second Line	:	#300
City	:	HOUSTON
State	:	TX
Zip	:	77056-3404
Country	:	US
Telephone Number	:	713-621-4424
Fax Number	:	713-621-4430

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	07/08/2007

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