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General NPI Number Information
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NPI Number | 1205419355
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Entity Type | Individual
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Provider Name | LISA REBECCA JOLLY DDS
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Gender | Female
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Dates
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Enumeration Date | 05/05/2021
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Last Update Date | 09/22/2022
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Provider Practice Location Address
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Address Line | 225 E CHICAGO AVE
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City | CHICAGO
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State | IL
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Zip | 60611-2991
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Country | US
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Telephone | 312-227-4000
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Fax |
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Provider Business Mailing Address
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Address Line | 30 N 1900 E # 3B400
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City | SALT LAKE CITY
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State | UT
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Zip | 84132-0002
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Country | US
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Telephone | 801-581-8419
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12328725-9921
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 12328725-9921
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License Number State | UT
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