Provider Demographics
NPI:1144781006
Name:DOLAN, TERRANCE MATTHEW
Entity Type:Individual
Prefix:DR
First Name:TERRANCE
Middle Name:MATTHEW
Last Name:DOLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 GRAMERCY PL
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-2310
Mailing Address - Country:US
Mailing Address - Phone:201-421-1855
Mailing Address - Fax:
Practice Address - Street 1:940 BELMONT ST BLDG 5
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5596
Practice Address - Country:US
Practice Address - Phone:774-826-2458
Practice Address - Fax:774-826-1859
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program