Provider Demographics
NPI:1821167495
Name:DOLAN, KENNETH H (DMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:H
Last Name:DOLAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 VIRGINIA ST E
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301
Mailing Address - Country:US
Mailing Address - Phone:304-345-4960
Mailing Address - Fax:304-345-4969
Practice Address - Street 1:1217 VIRGINIA ST E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301
Practice Address - Country:US
Practice Address - Phone:304-345-4960
Practice Address - Fax:304-345-4969
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2275122300000X
WV601223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0137878000Medicaid