Provider Demographics
NPI:1487483566
Name:DOLAN, SAMUEL ROBERT (DMD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ROBERT
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 1:70 COBBLESTONE LN
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03109-5942
Mailing Address - Country:US
Mailing Address - Phone:603-703-7212
Mailing Address - Fax:
Practice Address - Street 1:240 S 40TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-6030
Practice Address - Country:US
Practice Address - Phone:215-573-2588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NH052281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program