=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720413768
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JIM H. POLLES, D.M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2013
-----------------------------------------------------
Last Update Date | 09/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1836 CRANE RIDGE DR SUITE A
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-4901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-362-1118
-----------------------------------------------------
Fax | 601-362-3113
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1836 CRANE RIDGE DR SUITE A
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-4901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-362-1118
-----------------------------------------------------
Fax | 601-362-3113
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. JIM H POLLES
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 601-362-1118
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 3402-06
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------