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General NPI Number Information
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NPI Number | 1760630610
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Entity Type | Individual
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Provider Name | STEPHANIE D JOLY D.D.S
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Gender | Female
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Dates
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Enumeration Date | 09/04/2008
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Last Update Date | 01/11/2022
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Provider Practice Location Address
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Address Line | 2646 LOIS ST
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City | PORTAGE
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State | IN
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Zip | 46368-3500
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Country | US
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Telephone | 219-762-4266
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Fax | 219-762-2252
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Provider Business Mailing Address
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Address Line | 2646 LOIS ST
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City | PORTAGE
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State | IN
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Zip | 46368-3500
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Country | US
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Telephone | 219-762-4266
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Fax | 219-762-2252
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019.027751
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 12011254A
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License Number State | IN
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