Healthcare Provider Details

I. General information

NPI: 1205419355
Provider Name (Legal Business Name): LISA REBECCA JOLLY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E ERIE AVE
PHILADELPHIA PA
19134-1011
US

IV. Provider business mailing address

160 E ERIE AVE
PHILADELPHIA PA
19134-1011
US

V. Phone/Fax

Practice location:
  • Phone: 215-427-5000
  • Fax:
Mailing address:
  • Phone: 801-581-8419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12328725-9921
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS044929
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: