Healthcare Provider Details

I. General information

NPI: 1043430176
Provider Name (Legal Business Name): WILLIAM HARRISON JOLLY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 SOUTH MORRIS STREET
MEXICO MO
65265-2238
US

IV. Provider business mailing address

1415 SOUTH MORRIS STREET
MEXICO MO
65265-2238
US

V. Phone/Fax

Practice location:
  • Phone: 573-581-0511
  • Fax: 573-581-0511
Mailing address:
  • Phone: 573-581-0511
  • Fax: 573-581-0511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12295
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: