Provider Demographics
NPI:1205950292
Name:DOLAN, DAVID WILLIAM (LMT-MASSAGE THERA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:WILLIAM
Last Name:DOLAN
Suffix:
Gender:M
Credentials:LMT-MASSAGE THERA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2462
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-2462
Mailing Address - Country:US
Mailing Address - Phone:505-947-0112
Mailing Address - Fax:
Practice Address - Street 1:575 RIVERGATE
Practice Address - Street 2:SUITE 95
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7487
Practice Address - Country:US
Practice Address - Phone:505-947-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA# 10055225700000X
CO7499225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL593341785OtherFEIN
CO7499OtherLICENSED MASSAGE THERAPIST
FLMA# 10055OtherLIC. MASSAGE THERAPIST