Provider Demographics
NPI:1922278498
Name:BOLAN, TERRY E (DDS)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:E
Last Name:BOLAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 N WATER ST
Mailing Address - Street 2:926
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202
Mailing Address - Country:US
Mailing Address - Phone:414-276-6583
Mailing Address - Fax:414-276-8077
Practice Address - Street 1:735 N WATER ST
Practice Address - Street 2:926
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202
Practice Address - Country:US
Practice Address - Phone:414-276-6583
Practice Address - Fax:414-276-8077
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4155122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist