Healthcare Provider Details

I. General information

NPI: 1760046767
Provider Name (Legal Business Name): RYAN M DOLAN LAT, ATC, OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 BARRA RD STE 103
BIDDEFORD ME
04005-9461
US

IV. Provider business mailing address

46 BARRA RD
BIDDEFORD ME
04005-9459
US

V. Phone/Fax

Practice location:
  • Phone: 207-283-1126
  • Fax: 207-294-3544
Mailing address:
  • Phone: 207-283-1126
  • Fax: 207-294-3544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT735
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number19-0208
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: