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General NPI Number Information
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NPI Number | 1437414166
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Entity Type | Organization
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Legal Business Name | MARKHAM STREET DENTAL
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Dates
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Enumeration Date | 07/09/2012
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Last Update Date | 07/09/2012
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Provider Practice Location Address
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Address Line | 10220 W MARKHAM ST SUITE 101
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City | LITTLE ROCK
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State | AR
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Zip | 72205-2189
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Country | US
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Telephone | 501-666-7602
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Fax |
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Provider Business Mailing Address
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Address Line | 10220 W MARKHAM ST SUITE 101
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City | LITTLE ROCK
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State | AR
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Zip | 72205-2184
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Country | US
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Telephone | 501-666-7602
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ROBERT LEE JOLLY SR.
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Credential | DR
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Telephone | 501-352-6580
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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 |
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License Number State |
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